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Personality Disorders
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This chapter begins with a general definition of personality disorder that applies to each of the 10 specific

personality disorders. A personality disorder is an enduring pattern of inner experience and behavior that

deviates markedly from the norms and expectations of the individual’s culture, is pervasive and inflexible, has

an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.

With any ongoing review process, especially one of this complexity, different viewpoints emerge, and an effort

was made to accommodate them. Thus, personality disorders are included in both Sections II and III. The

material in Section II represents an update of text associated with the same criteria found in DSM-5 (which
were carried over from DSM-IV-TR), whereas Section III includes the proposed model for personality disorder

diagnosis and conceptualization developed by the DSM-5 Personality and Personality Disorders Work Group. As
this field evolves, it is hoped that both versions will serve clinical practice and research initiatives, respectively.

The following personality disorders are included in this chapter.

▫ Paranoid personality disorder is a pattern of distrust and suspiciousness such that others’ motives are
interpreted as malevolent.

▫ Schizoid personality disorder is a pattern of detachment from social relationships and a restricted range of
emotional expression.

▫ Schizotypal personality disorder is a pattern of acute discomfort in close relationships, cognitive or

perceptual distortions, and eccentricities of behavior.

▫ Antisocial personality disorder is a pattern of disregard for, and violation of, the rights of others,
criminality, impulsivity, and a failure to learn from experience.

▫ Borderline personality disorder is a pattern of instability in interpersonal relationships, self-image, and

affects, and marked impulsivity.

▫ Histrionic personality disorder is a pattern of excessive emotionality and attention seeking.

▫ Narcissistic personality disorder is a pattern of grandiosity, need for admiration, and lack of empathy.

▫ Avoidant personality disorder is a pattern of social inhibition, feelings of inadequacy, and hypersensitivity
to negative evaluation.

▫ Dependent personality disorder is a pattern of submissive and clinging behavior related to an excessive
need to be taken care of.

▫ Obsessive-compulsive personality disorder is a pattern of preoccupation with orderliness, perfectionism,

and control.

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▫ Personality change due to another medical condition is a persistent personality disturbance that is
judged to be the direct pathophysiological consequence of another medical condition (e.g., frontal lobe
lesion).

▫ Other specified personality disorder is a category provided for two situations: 1) the individual’s
personality pattern meets the general criteria for a personality disorder, and traits of several different
personality disorders are present, but the criteria for any specific personality disorder are not met; or 2) the
individual’s personality pattern meets the general criteria for a personality disorder, but the individual is
considered to have a personality disorder that is not included in the DSM-5 classification (e.g., passive-
aggressive personality disorder). Unspecified personality disorder is for presentations in which symptoms
characteristic of a personality disorder are present but there is insufficient information to make a more
specific diagnosis.

The personality disorders are grouped into three clusters based on descriptive similarities. Cluster A includes

paranoid, schizoid, and schizotypal personality disorders. Individuals with these disorders often appear odd or
eccentric. Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders. Individuals

with these disorders often appear dramatic, emotional, or erratic. Cluster C includes avoidant, dependent, and

obsessive-compulsive personality disorders. Individuals with these disorders often appear anxious or fearful. It
should be noted that this clustering system, although useful in some research and educational situations, has

serious limitations and has not been consistently validated. For instance, two or more disorders from different

clusters, or traits from several of them, can often co-occur and vary in intensity and pervasiveness.

A review of epidemiological studies from several countries found a median prevalence of 3.6% for disorders in

Cluster A, 4.5% for Cluster B, 2.8% for Cluster C, and 10.5% for any personality disorder (Huang et al. 2009;

Morgan and Zimmerman 2018). Prevalence appears to vary across countries and by ethnicity, raising questions

about true cross-cultural variation and about the impact of diverse definitions and diagnostic instruments on
prevalence assessments (McGilloway et al. 2010; Tyrer et al. 2010).

Dimensional Models for Personality Disorders

The diagnostic approach used in this manual represents the categorical perspective that personality disorders
are qualitatively distinct clinical syndromes. An alternative to the categorical approach is the dimensional

perspective that personality disorders represent maladaptive variants of personality traits that merge

imperceptibly into normality and into one another. See Section III for a full description of a dimensional model

for personality disorders. The DSM-5 personality disorder clusters (i.e., odd-eccentric, dramatic-emotional, and
anxious-fearful) may also be viewed as dimensions representing spectra of personality dysfunction on a

continuum with other mental disorders. The alternative dimensional models have much in common and

together appear to cover the important areas of personality dysfunction. Their integration, clinical utility, and

relationship with the personality disorder diagnostic categories and various aspects of personality dysfunction

continue to be under active investigation. This includes research on whether the dimensional model can clarify
the cross-cultural prevalence variations seen with the categorical model (Alarcón et al. 1998; McGilloway et al.

2010; Tyrer et al. 2010).

References

Alarcón RD, Foulks EF, Vakkur M: Personality Disorders and Culture: Clinical and Conceptual Interactions. New York, Wiley, 1998

 Go to Citation | Google Scholar

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Huang Y, Kotov R, de Girolamo G, et al: DSM-IV personality disorders in the WHO World Mental Health Surveys. Br J Psychiatry 195(1):46–53,
2009

 Go to Citation | PubMed | Google Scholar

McGilloway A, Hall RE, Lee T, Bhui KS: A systematic review of personality disorder, race and ethnicity: prevalence, aetiology and treatment.
BMC Psychiatry 10:33, 2010

 Show Citations | PubMed | Google Scholar

Morgan TA, Zimmerman M: Epidemiology of personality disorders, in Handbook of Personality Disorders: Theory, Research, and Treatment,
2nd Edition. Edited by Livesley WJ, Larstone R. New York, Guilford, 2018, pp 173–196

 Go to Citation | Google Scholar

Tyrer P, Mulder R, Crawford M, et al: Personality disorder: a new global perspective. World Psychiatry 9(1):56–60, 2010

 Show Citations | PubMed | Google Scholar

General Personality Disorder

Criteria

A. An enduring pattern of inner experience and behavior that deviates markedly from
the expectations of the individual’s culture. This pattern is manifested in two (or more)
of the following areas:

1. Cognition (i.e., ways of perceiving and interpreting self, other people, and events).
2. Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional
response).
3. Interpersonal functioning.
4. Impulse control.

B. The enduring pattern is inflexible and pervasive across a broad range of personal and
social situations.
C. The enduring pattern leads to clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
D. The pattern is stable and of long duration, and its onset can be traced back at least to
adolescence or early adulthood.
E. The enduring pattern is not better explained as a manifestation or consequence of
another mental disorder.
F. The enduring pattern is not attributable to the physiological effects of a substance
(e.g., a drug of abuse, a medication) or another medical condition (e.g., head trauma).

Diagnostic Features

Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and

oneself that are exhibited in a wide range of social and personal contexts. Only when personality traits are

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inflexible and maladaptive and cause significant functional impairment or subjective distress do they constitute
personality disorders. The essential feature of a personality disorder is an enduring pattern of inner experience

and behavior that deviates markedly from the norms and expectations of the individual’s culture and is

manifested in at least two of the following areas: cognition, affectivity, interpersonal functioning, or impulse

control (Criterion A). This enduring pattern is inflexible and pervasive across a broad range of personal and

social situations (Criterion B) and leads to clinically significant distress or impairment in social, occupational, or

other important areas of functioning (Criterion C). The pattern is stable and of long duration, and its onset can
be traced back at least to adolescence or early adulthood (Criterion D). The pattern is not better explained as a

manifestation or consequence of another mental disorder (Criterion E) and is not attributable to the

physiological effects of a substance (e.g., a drug of abuse, a medication, exposure to a toxin) or another

medical condition (e.g., head trauma) (Criterion F). Specific diagnostic criteria are also provided for each of the

personality disorders included in this chapter.

The diagnosis of personality disorders requires an evaluation of the individual’s long-term patterns of

functioning, and the particular personality features must be evident by early adulthood. The personality traits

that define these disorders must also be distinguished from characteristics that emerge in response to specific

situational stressors or more transient mental states (e.g., bipolar, depressive, or anxiety disorders; substance

intoxication). The clinician should assess the stability of personality traits over time and across different
situations. Although a single interview with the individual is sometimes sufficient for making the diagnosis, it is

often necessary to conduct more than one interview and to space these over time. Assessment can also be

complicated by the fact that the characteristics that define a personality disorder may not be considered

problematic by the individual (i.e., the traits are often ego-syntonic). To help overcome this difficulty,

supplementary information from other informants may be helpful.

Development and Course

The features of a personality disorder usually become recognizable during adolescence or early adult life. By

definition, a personality disorder is an enduring pattern of thinking, feeling, and behaving that is relatively
stable over time. Some types of personality disorder (notably, antisocial and borderline personality disorders)

tend to become less evident or to remit with age, whereas this appears to be less true for some other types
(e.g., obsessive-compulsive and schizotypal personality disorders).

Personality disorder categories may be applied with children or adolescents in those relatively unusual

instances in which the individual’s particular maladaptive personality traits appear to be pervasive, persistent,
and unlikely to be limited to a particular developmental stage or attributable to another mental disorder. It

should be recognized that the traits of a personality disorder that appear in childhood will often not persist
unchanged into adult life. For a personality disorder to be diagnosed in an individual younger than 18 years,

the features must have been present for at least 1 year. The one exception to this is antisocial personality
disorder, which cannot be diagnosed in individuals younger than 18 years. Although, by definition, a
personality disorder requires an onset no later than early adulthood, individuals may not come to clinical

attention until relatively late in life. A personality disorder may be exacerbated following the loss of significant
supporting persons (e.g., a spouse) or previously stabilizing social situations (e.g., a job). However, the

development of a change in personality in middle adulthood or later life warrants a thorough evaluation to

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determine the possible presence of a personality change due to another medical condition or an unrecognized

substance use disorder.

Culture-Related Diagnostic Issues

Core aspects of personality like emotion regulation and interpersonal functioning are influenced by culture,

which also provides means of protection and assimilation and norms for acceptance and denunciation of
specific behaviors and personality traits (Ronningstam et al. 2018). Judgments about personality functioning

must take into account the individual’s ethnic, cultural, and social background. Personality disorders should not
be confused with problems associated with acculturation following migration or with the expression of habits,
customs, or religious and political values based on the individual’s cultural background or context. Behavioral

patterns that appear to be rigid and dysfunctional aspects of personality disorder may reflect instead adaptive
responses to cultural constraints (Balaratnasingam and Janca 2017; Fang et al. 2016; Ronningstam et al. 2018;

Ryder et al. 2014). For example, reliance on an abusive relationship in a small community where divorce is
proscribed may not reflect pathological dependence; conscientious political protest that puts friends and family

members at risk with authorities or in conflict with legal norms does not necessarily reflect pathological
callousness (Ryder et al. 2014). There are marked variations in the recognition and diagnosis of personality
disorders across cultural, ethnic, and racialized groups (Alarcón et al. 1998; McGilloway et al. 2010; Tyrer et al.

2010). Accuracy of diagnosis can be enhanced by attention to culturally patterned conceptions of self and
attachment, assessment biases resulting from clinicians’ own cultural backgrounds or use of diagnostic

instruments that are not normed to the population being assessed, and the impact of social determinants such
as poverty, acculturative stress, racism, and discrimination on feelings, cognitions, and behaviors (Iacovino et al.
2014; Raza et al. 2014; Ryder et al. 2014). It is useful for the clinician, especially when evaluating someone from

a different background, to obtain additional information from informants who are familiar with the person’s
cultural background.

Sex- and Gender-Related Diagnostic Issues

Certain personality disorders (e.g., antisocial personality disorder) are diagnosed more frequently in men.
Others (e.g., borderline, histrionic, and dependent personality disorders) are diagnosed more frequently in
women; however, in the case of borderline personality disorder, this may be due to higher help-seeking among

women. Nonetheless, clinicians must be cautious not to overdiagnose or underdiagnose certain personality
disorders in women or in men because of social stereotypes about typical gender roles and behaviors. There is

currently insufficient evidence on differences between cis- and transgender individuals with respect to the
epidemiology or clinical presentations of personality disorders to draw meaningful conclusions.

Differential Diagnosis
Other mental disorders and personality traits

Many of the specific criteria for the personality disorders describe features (e.g., suspiciousness, dependency,

insensitivity) that are also characteristic of episodes of other mental disorders. A personality disorder should be
diagnosed only when the defining characteristics appeared before early adulthood, are typical of the
individual’s long-term functioning, and do not occur exclusively during an episode of another mental disorder.

It may be particularly difficult (and not particularly useful) to distinguish personality disorders from persistent
mental disorders such as persistent depressive disorder that have an early onset and an enduring, relatively

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stable course. Some personality disorders may have a “spectrum” relationship to other mental disorders (e.g.,
schizotypal personality disorder with schizophrenia; avoidant personality disorder with social anxiety disorder)

based on phenomenological or biological similarities or familial aggregation.

Personality disorders must be distinguished from personality traits that do not reach the threshold for a
personality disorder. Personality traits are diagnosed as a personality disorder only when they are inflexible,

maladaptive, and persisting and cause significant functional impairment or subjective distress.

Psychotic disorders

For the three personality disorders that may be related to the psychotic disorders (i.e., paranoid, schizoid, and

schizotypal), there is an exclusion criterion stating that the pattern of behavior must not have occurred
exclusively during the course of schizophrenia, a bipolar or depressive disorder with psychotic features, or

another psychotic disorder. When an individual has a persistent mental disorder (e.g., schizophrenia) that was
preceded by a preexisting personality disorder, the personality disorder should also be recorded, followed by

“premorbid” in parentheses.

Anxiety and depressive disorders

The clinician must be cautious in diagnosing personality disorders during an episode of a depressive disorder

or an anxiety disorder, because these conditions may have cross-sectional symptom features that mimic
personality traits and may make it more difficult to evaluate retrospectively the individual’s long-term patterns

of functioning.

Posttraumatic stress disorder

When personality changes emerge and persist after an individual has been exposed to extreme stress, a
diagnosis of posttraumatic stress disorder should be considered.

Substance use disorders

When an individual has a substance use disorder, it is important not to make a personality disorder diagnosis
based solely on behaviors that are consequences of substance intoxication or withdrawal or that are associated

with activities in the service of sustaining substance use (e.g., antisocial behavior).

Personality change due to another medical condition

When enduring changes in personality arise as a result of the physiological effects of another medical condition
(e.g., brain tumor), a diagnosis of personality change due to another medical condition should be considered.

References

Alarcón RD, Foulks EF, Vakkur M: Personality Disorders and Culture: Clinical and Conceptual Interactions. New York, Wiley, 1998

 Go to Citation | Google Scholar

Balaratnasingam S, Janca A: Culture and personality disorder: a focus on indigenous Australians. Curr Opin Psychiatry 30(1):31–35, 2017

 Go to Citation | PubMed | Google Scholar

Fang K, Friedlander M, Pieterse AL: Contributions of acculturation, enculturation, discrimination, and personality traits to social anxiety among
Chinese immigrants: a context-specific assessment. Culture Divers Ethnic Minor Psychol 22(1):58–68, 2016

 Go to Citation | PubMed | Google Scholar

https://psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x18_Personality_Disorders 6/66
7/15/25, 2:54 PM Personality Disorders | Psychiatry Online

Iacovino JM, Jackson JJ, Oltmanns TF: The relative impact of socioeconomic status and childhood trauma on Black-White differences in
paranoid personality disorder symptoms. J Abnorm Psychol 123(1):225–230, 2014

 Go to Citation | PubMed | Google Scholar

McGilloway A, Hall RE, Lee T, Bhui KS: A systematic review of personality disorder, race and ethnicity: prevalence, aetiology and treatment.
BMC Psychiatry 10:33, 2010

 Go to Citation | PubMed | Google Scholar

Raza GT, DeMarce JM, Lash SJ, Parker JD: Paranoid personality disorder in the United States: the role of race, illicit drug use, and income. J
Ethn Subst Abuse 13(3):247–257, 2014

 Go to Citation | PubMed | Google Scholar

Ronningstam EF, Keng S-L, Ridolfi ME et al. Cultural aspects in symptomatology, assessment, and treatment of personality disorders. Curr
Psychiatry Rep 20(4):22, 2018 29582187

 Show Citations | Google Scholar

Ryder AG, Dere J, Sun J, Chentsova-Dutton YE: The cultural shaping of personality disorder, in APA Handbook of Multicultural Psychology.
Edited by Leong FTL, Comas-Diaz L, Hall GCN, et al. Washington, DC, American Psychological Association, 2014, pp 307–328

 Show Citations | Google Scholar

Tyrer P, Mulder R, Crawford M, et al: Personality disorder: a new global perspective. World Psychiatry 9(1):56–60, 2010

 Go to Citation | PubMed | Google Scholar

Cluster A Personality Disorders

Paranoid Personality Disorder

(F60.0) 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.

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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,” i.e.,
“paranoid personality disorder (premorbid).”

Diagnostic Features

The essential feature of paranoid personality disorder is a pattern of pervasive distrust and suspiciousness of

others such that their motives are interpreted as malevolent. This pattern begins by early adulthood and is
present in a variety of contexts.

Individuals with this disorder assume that other people will exploit, harm, or deceive them, even if no evidence
exists to support this expectation (Criterion A1). They suspect on the basis of little or no evidence that others

are plotting against them and may attack them suddenly, at any time and without reason. They often feel that

they have been deeply and irreversibly injured by another person or persons even when there is no objective
evidence for this. They are preoccupied with unjustified doubts about the loyalty or trustworthiness of their

friends and associates, whose actions are minutely scrutinized for evidence of hostile intentions (Criterion A2).

Any perceived deviation from trustworthiness or loyalty serves to support their underlying assumptions. They

are so amazed when a friend or associate shows loyalty that they cannot trust or believe it. If they get into
trouble, they expect that friends and associates will either attack or ignore them.

Individuals with paranoid personality disorder are reluctant to confide in or become close to others because

they fear that the information they share will be used against them (Criterion A3). They may refuse to answer

personal questions, saying that the information is “nobody’s business.” They read hidden meanings that are
demeaning and threatening into benign remarks or events (Criterion A4). For example, an individual with this

disorder may misinterpret an honest mistake by a store clerk as a deliberate attempt to shortchange, or view a

casual humorous remark by a coworker as a serious character attack. Compliments are often misinterpreted

(e.g., a compliment on a new acquisition is misinterpreted as a criticism for selfishness; a compliment on an

accomplishment is misinterpreted as an attempt to coerce more and better performance). They may view an

offer of help as a criticism that they are not doing well enough on their own.

Individuals with this disorder persistently bear grudges and are unwilling to forgive the insults, injuries, or

slights that they think they have received (Criterion A5). Minor slights arouse major hostility, and the hostile

feelings persist for a long time. Because they are constantly vigilant to the harmful intentions of others, they
very often feel that their character or reputation has been attacked or that they have been slighted in some

other way. They are quick to counterattack and react with anger to perceived insults (Criterion A6). Individuals

with this disorder may be pathologically jealous, often suspecting that their spouse or sexual partner is
unfaithful without any adequate justification (Criterion A7). They may gather trivial and circumstantial

“evidence” to support their jealous beliefs. They want to maintain complete control of intimate relationships to

avoid being betrayed and may constantly question and challenge the whereabouts, actions, intentions, and
fidelity of their spouse or partner.

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Paranoid personality disorder should not be diagnosed if the pattern of behavior occurs exclusively during the

course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic
disorder, or if it is attributable to the physiological effects of a neurological (e.g., temporal lobe epilepsy) or

another medical condition (Criterion B).

Associated Features

Individuals with paranoid personality disorder are generally difficult to get along with and often have problems

with close relationships. Their excessive suspiciousness and hostility may be expressed in overt
argumentativeness, in recurrent complaining, or by hostile aloofness. They display a labile range of affect, with

hostile, stubborn, and sarcastic expressions predominating. Their combative and suspicious nature may elicit a

hostile response in others, which then serves to confirm their original expectations.

Because individuals with paranoid personality disorder lack trust in others, they need to have a high degree of
control over those around them. They are often rigid, critical of others, and unable to collaborate, although

they have great difficulty accepting criticism themselves. They may blame others for their own shortcomings.

Because of their quickness to counterattack in response to the threats they perceive around them, they may be

litigious and frequently become involved in legal disputes. Individuals with this disorder seek to confirm their
preconceived negative notions regarding people or situations they encounter, attributing malevolent

motivations to others that are projections of their own fears. They may exhibit thinly hidden, unrealistic

grandiose fantasies, are often attuned to issues of power and rank, and tend to develop negative stereotypes of
others, particularly those from population groups distinct from their own. Attracted by simplistic formulations

of the world, they are often wary of ambiguous situations. They may be perceived as “fanatics” and form tightly

knit “cults” or groups with others who share their paranoid belief systems.

Prevalence

The estimated prevalence of paranoid personality based on a probability subsample from Part II of the National
Comorbidity Survey Replication was 2.3% (Lenzenweger et al. 2007). The prevalence of paranoid personality

disorder in the National Epidemiologic Survey on Alcohol and Related Conditions was 4.4% (Grant et al. 2004).

A review of six epidemiological studies (four in the United States) found a median prevalence of 3.2% (Morgan

and Zimmerman 2018). In forensic settings, the estimated prevalence may be as high as 23% (Ullrich et al.
2008).

Development and Course

Paranoid personality disorder may be first apparent in childhood and adolescence with solitariness, poor peer

relationships, social anxiety, underachievement in school, and interpersonal hypersensitivity. Adolescent onset

of paranoid personality disorder is associated with a prior history of childhood maltreatment, externalizing

symptoms, bullying of peers, and adult appearance of interpersonal aggression (Johnson et al. 2000; Natsuaki
et al. 2009).

Risk and Prognostic Factors

Environmental

Exposure to social stressors such as socioeconomic inequality, marginalization, and racism is associated with

decreased trust, which in some cases is adaptive. The combination of social stress and childhood maltreatment
accounts for the increased prevalence of paranoid symptoms in social groups facing racial discrimination

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(Iacovino et al. 2014). Both longitudinal (Natsuaki et al. 2009) and cross-sectional studies confirm that

childhood trauma is a risk factor for paranoid personality disorder (Lee 2017).

Genetic and physiological

There is some evidence for an increased prevalence of paranoid personality disorder in relatives of probands

with schizophrenia and for a more specific familial relationship with delusional disorder, persecutory type
(Kendler et al. 1985).

Culture-Related Diagnostic Issues

Some behaviors that are influenced by sociocultural contexts or specific life circumstances may be erroneously

labeled paranoid and may even be reinforced by the process of clinical evaluation. Migrants, members of

socially oppressed ethnic and racialized populations, and other groups facing social adversity, racism, and
discrimination may display guarded or defensive behaviors because of unfamiliarity (e.g., language barriers or

lack of knowledge of rules and regulations) or in response to the neglect, hostility, or indifference of the

majority society (Iacovino et al. 2014; Raza et al. 2014). Some cultural groups develop low generalized trust,
especially of outgroup members, which may lead to behaviors that can be misjudged as paranoid. These

include guardedness, limited outward emotionality, cognitive rigidity, social distance, and hostility or

defensiveness in situations experienced as unfair or discriminatory (Combs et al. 2002; Mosley et al. 2017; van

der Linden 2017; Van Hoorn 2015; Whaley 2004). These behaviors can, in turn, generate anger and frustration in
others, including clinicians, thus setting up a vicious cycle of mutual mistrust, which should not be confused

with paranoid traits or paranoid personality disorder (Ahmed et al. 2017; Isbell et al. 2020).

Sex- and Gender-Related Diagnostic Issues

While paranoid personality disorder was found to be more common in men than in women in a meta-analysis

relying on clinical and community samples (Lynam and Widiger 2007), the National Epidemiologic Survey on
Alcohol and Related Conditions found it to be more common in women (Grant et al. 2004).

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 a direct physiological consequence of another medical condition.

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

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