Therapy for paranoid personality disorder: Effective techniques

A diagnosis of paranoid personality disorder means far more than tending to look over your shoulder or a casual interest in conspiracy theories. It’s a mental health condition that can negatively impact a person’s life and relationships. Typically characterized by extreme paranoia and suspicion, paranoid personality disorder can cause people to ostracize themself from their community because of an inability to trust anyone.

Specific therapies may be effective in addressing the symptoms of paranoid personality disorder.

What is paranoid personality disorder? 

Paranoid personality disorder (PPD) is a Cluster A personality disorder. Otherwise called eccentric personality disorders, Cluster A disorders often cause patients to experience unusual or eccentric thought patterns. Symptoms can include atypical behaviors and difficulty forming, building, and maintaining relationships, in large part because their behavior may be complex for other people to understand. Another common symptom is paranoia around people and about interactions, relationships, and events.

Though the types of Cluster A personality disorder might share certain similarities, paranoid personality disorder stands out for making people exhibit a long-term pattern of suspicion and distrust of others. Someone with paranoid personality disorder may experience symptoms like: 

• Frequently misinterpreting friendly or neutral interactions and perceiving them as negative or outright hostile
• Suspicion of other people in their lives, often manifesting as a belief that people are trying to lie to them or manipulate them 
• Fear of confiding in people, possibly out of a belief that in opening up to others, their vulnerability will eventually be used against them 
• Social withdrawal, detachment, and isolation
• Finding hidden, often malicious meanings in typical or straightforward gestures, facial expressions, statements, and conversations
• Extreme sensitivity to criticism or rejection
• Experiencing anger towards people they believe have mistreated them and refusing to accept any apology
• Inclination to hold grudges
• Being argumentative and stubborn
• Difficulty collaborating with other people on projects at work or school
• Inability to understand their role in conflicts with others
• A belief that they are always right
• Preoccupation with conspiracy theories
• Anxiety

It may be helpful to note that while PPD and the other Cluster A personality disorders may have some similar symptoms to schizophrenia and other forms of psychosis, they are distinct from psychotic mental disorders. Symptoms of psychotic disorders can include hallucinations and delusions, whereas personality disorders involve unhealthy behavioral and thought patterns. 

How is paranoid personality disorder diagnosed?

Paranoid personality disorder can be diagnosed in a similar manner to other related mental health conditions. The first step is typically a physical exam administered by a doctor to determine that there is no physical health condition that may be causing the PPD symptoms. This examination may include a blood test and other types of screenings.

After the physical exam has ruled out any physical health complications, a doctor or mental health professional will likely conduct a psychological exam. This evaluation typically involves talking to the patient about their thoughts, feelings, and behaviors. In the case of personality disorders like PPD, the healthcare professional may also consult with people close to the patient.

The psychological exam results are typically compared to the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), the official mental health diagnosis and care standard. 

How is paranoid personality disorder treated?

It can be challenging for mental health professionals to treat people with paranoid personality disorder. General treatments for personality disorders are often used to treat PPD, including talk therapy and certain medications. Many talk therapy treatments, which can effectively address PPD symptoms, rely on a solid relationship between clients and their therapists. 

An inherent characteristic of PPD is distrust of others and avoidance of situations where one could be emotionally vulnerable, so building a bond between a therapist and a client with PPD can be complicated. As can be the case with many types of personality disorders, people with PPD often do not understand anything problematic about their behavior and may be unwilling to seek treatment. 

With that being said, if people with PPD reach out to a therapist for help (potentially because a loved one has asked them to), some treatments can make a difference.

Dialectical behavior therapy

Dialectical behavior therapy, often abbreviated to DBT, focuses on four key skill areas: mindfulness, emotion regulation, interpersonal effectiveness, and distress tolerance. The main goals of DBT include helping a person understand themselves better and increasing general coping skills through higher levels of awareness and behavioral intervention. 

DBT can work to address specific symptoms of PPD. Paranoia is a form of emotional dysregulation, so learning more emotional stabilization skills can be beneficial. 

People practicing DBT skills can often become more adept at acknowledging and labeling their feelings, which can act as a counterweight to paranoia. DBT may also help people with PPD cope with other strong emotions related to the disorder, such as anger, fear, suspicion, anxiety, and hostility.

Cognitive behavioral therapy

Cognitive behavioral therapy, or CBT, is one of the most widely practiced forms of treatment. Many psychologists and experts in human behavior consider CBT the gold standard of treatment options for various mental health conditions, including common personality disorders. 

CBT typically operates on the premise that there is a fundamental link between how a person thinks and how they behave, so changing unhelpful thought patterns can make a difference in reducing undesirable behaviors.

Through CBT, a patient with PPD may become more aware of paranoid thoughts, leading them to shift those thoughts and begin seeing the world as it is. In understanding their paranoia better, they may be able to start dismantling the belief that their suspicions and paranoid attitudes are reasonable. CBT may also help increase self-esteem, which can contribute to combating some PPD symptoms based on anxiety and insecurity. 

Reality testing

Reality testing is a form of psychotherapy that encourages people to examine the difference between their belief systems and their experiences with reality. It can be one of the most effective treatments for paranoid personality disorder.

Here is a typical way a therapist may deploy reality testing with a client who has PPD:

1. Imagine that the client expresses an irrational belief that their spouse is cheating on them because they are always coming home late.
2. To reality-test the belief, the therapist and the client may look at the situation to determine if there is evidence for the belief or evidence for another situation. For instance, perhaps the spouse works on an intense project that keeps them at the office outside their regular hours.
3. With practice, the client may learn to begin automatically implementing reality testing measures whenever they encounter a thought based on paranoia or suspicion, dismantling their automated reactions.

Finding support for paranoid personality disorder through online therapy

In some cases, it might be complicated for a person with paranoid personality disorder to find a therapist they can connect with and feel comfortable opening up to. It may be beneficial for a client with PPD to consider online therapy. Interacting with a therapist over a phone or computer screen may empower the client to feel more in control and potentially lead to them letting down their guard more than in a traditional therapeutic setting. Additionally, online therapy can be more easily accessed since you may not have to leave the comfort of your home to attend sessions.

Scientific research has demonstrated the efficacy of online therapy for treating various mental health conditions, including personality disorders. One study reviewed existing research on the topic and found that online therapy can help reduce personality disorder symptoms and potentially be less expensive than in-person therapy. If symptoms of PPD negatively affect your life, you may want to consider contacting an online therapist.