Personality and Mental Health

7: 254–258 (2013)
Published online in Wiley Online Library
(wileyonlinelibrary.com) DOI 10.1002/pmh.1244

Complex Case
Paranoid personality disorder and the
schizophrenia spectrum—Where to draw
the line?

SØREN FRYD BIRKELAND, Department of Psychiatry, Svendborg Hospital, Vaengevej 22, DK-5772
Kvaerndrup, Denmark

ABSTRACT
By means of a case vignette, this study explores the clinical intersection between paranoid personality disorder
and other schizophrenia-spectrum illness. Even though the patient described had paramount signs of a paranoid
personality disorder and was diagnosed as such, psychopathological symptoms extended considerably beyond the
common concept and diagnostic criteria of the disorder. Management strategies included psychopharmacological
and non-pharmacological interventions, yet psychosocial functioning permanently appeared defective. While
there is a persistent need for an opportunity to distinguish the characteristic syndromal pattern of paranoid
personality attributes, the case exemplifies the challenges associated with classifying some largely suspicious
and distrustful eccentrics within the schizophrenia spectrum. Copyright © 2013 John Wiley & Sons, Ltd.

Introduction Paranoid personality disorder is an adult mental

The current reconceptualization of the personality
disorder nomenclature concerns not least the
‘eccentric’ variety of personalities. One representa-
tive of the latter is schizoid personality disorder.
Nirestean, Lukacs, Cimpan and Taran (2012)
recently demonstrated the challenges associated
with both diagnosing and managing patients
suspected of this disorder; particular difficulties
arose with distinguishing schizoid personality
disorder from another eccentric variant,
schizotypal disorder. The theme of this case
presentation is paranoid personality disorder
(PPD) which is the residual representative of the
eccentric character types.
disorder that is typically characterized by features like
suspiciousness and distrust. The disorder was early on
described by leading psychiatrists (see, e.g. Meyer
1903), and at present, it is included both in DSM-
IV-TR and ICD-10 (APA, 2000; WHO, 1993) with
relatively similar trait-concept definitions (Ottoson,
Ekselius, Grann, & Kullgren, 2002). Nevertheless,
the diagnostic status of PPD has been repeatedly
questioned, most recently, as indicated earlier, in
connection with the current revisions of the DSM
and ICD diagnostic systems. Concurrently, there is
a lack of clinical research evidence concerning PPD.
According to interview studies, PPD may be
relatively frequent in the community with preva-
lence rates as high as 2.4% (Torgersen, Kringlen, &

Copyright © 2013 John Wiley & Sons, Ltd. 7: 254–258 (2013)

DOI: 10.1002/pmh

Cramer, 2001). Still, subjects with PPD tend to
reject psychiatric intervention (Tyrer, Mitchard,
Methuen, & Ranger, 2003), and PPD may be rela-
tively uncommonly diagnosed in psychiatric
hospitals (Fulton & Winokur, 1993; Birkeland,
2011). What is more, patients with PPD are disin-
clined to participate in any research (Thompson-
Pope & Turkat, 1993).
In addition to being one of the eccentric
personality disorders, PPD is considered a member
of the so-called schizophrenia spectrum. This
spectrum also includes (broadly defined): schizophre-
nia; schizotypal, schizoid and avoidant personality
disorders; schizoaffective, schizophreniform and
delusional disorders; bipolar disorder with psychosis;
depressive disorder with psychosis; and unspecified
psychotic disorder (Tienari et al., 2003). Members
of the spectrum are deemed to have distinctive
psychopathological aspects in common and are
considered to be somehow genetically transmitted
with schizophrenia. In general, however, the qualita-
tive psychopathological similarities have received
scant research attention (Raballo & Parnas, 2011).
More specifically also, in regard to PPD, the clinical
implications of the spectrum membership remain
understudied. Anyhow, as the following case
diagnosed with PPD demonstrates, the intersection
with neighbouring spectrum illness may cause
considerable challenges in clinical practice.
Case report
Mrs A was admitted to psychiatric hospital in her
thirties. She was admitted according to a referral
from her family doctor under the diagnosis of
‘intermittently paranoid’. Before admission, she had
been assessed and declared motivated for treatment
in the outpatient clinic.
Family and personal antecedents
A few years previously, Mrs A had been to another
psychiatric hospital. In that connection, she was
observed ‘guarded’, ‘shy’, ‘tense’ and anxious, with
deficient emotional contact. Additionally, she had
Copyright © 2013 John Wiley & Sons, Ltd.
Complex paranoid personality case 255
proclaimed to ‘experience everything in sharp
colours’ and revealed ‘unrealistic thoughts’, and in-
termittently, she had been suspected of having hallu-
cinations. She had been attached to that hospital’s
day clinic for a couple of months and was subse-
quently discharged with fluphenazine under the diag-
noses of ‘reactive psychosis’ and PPD (ICD 8).
Purportedly, in childhood, Mrs A used to be a
joyful and extroverted person. Her mother was
described as having had ‘bad nerves’. In her early
teens, Mrs A’s parents divorced. From about that
point in time, she was increasingly withdrawn and
had a growing sense of being ‘splitted’, chaos of
thinking and feeling of self-insecurity. She had an
early sexual debut and reported to have been victim
of sexual assaults (by a non-family member) during
adolescence. In her twenties, after a few years of
marriage, she had a child. Unfortunately, her
husband was ailing and finally deceased. Afterwards,
from time to time, she had a boyfriend.
The history of the illness
For the most part, the present admission was socially
caused: Mrs A’s whole social situation concerning a
problematic relationship with an alcoholic boyfriend,
difficulties in caring for her child and problems in
working life had gradually worsened. As were her
mental troubles. Besides, she had developed a slight
alcohol abuse and occasionally took cannabis.
From admission onwards, she was described as
exceedingly distrustful, suspicious and intermittently
supposedly clear-cut paranoid. Her distrust and
suspiciousness were continuously defined in broad
terms—as an attitude towards the surroundings
which was never further explicated. Allegedly, she
had no experiences of, e.g. persecution; rather,
she claimed to express a ‘sound scepticism’. Once
she admitted that ‘she did not completely trust’ her
colleagues, yet the psychiatrists did not succeed to
delve more thoroughly into the matter. Her
behaviour always appeared tense and guarded. Intel-
lectually, she was categorized low in average area.
Emotional contact was slightly poor-modulated
and sometimes vastly defective. Recurrently, she
7: 254–258 (2013)
DOI: 10.1002/pmh
256 Birkeland
appeared anxious, and a few times, she had brief
episodes suspected of auditory and visual halluci-
nations. Likewise, there was a slight trend towards
subtle formal thought disorders with vague
thoughts, jumping of thoughts and faint ambiva-
lence. For instance, during one admission, she
pensively announced to aim at ‘progression to a
degree that she would know what fashion she
preferred her hair cut’.
Once it was speculated that Mrs A could possibly
suffer from a borderline personality disorder with
‘micro-psychotic breakthroughs’, and on another
occasion, it was suggested that there was ‘more in
the disease picture than just a disordered personality
structure’. Still, the distrustful, suspicious, tense and
guarded attitude was considered predominant. On
the top of it, instable affects played a shifting role.
Mrs A attended wide-ranging social psychiatric
care in connection with attachment to psychiatric
specialists, nurses and social workers and joined
extensive group therapeutic sessions. In this regard,
her psychosocial background, work-related worries
chiefly with collaborating with others, the problem-
atic motherhood with difficulties in communication
and her fear of losing the child appeared to be the
leading (almost stereotyped) themes. For a period
of time, depressed mood supervened with inability
to concentrate, a tendency towards insomnia and
suicidal ideation. As a consequence, citalopram
was administered (20 mg per day), which during a
3-week period proved to relieve depressive symptoms.
Successively, a minor hypomania was suspected.
During 10 years, Mrs A had three fairly similar
courses of outpatient treatment and one inpatient
admission. Fluphenazine (2 mg per day) was adminis-
tered for years; it was perceived subjectively benefi-
cial although treatment was discontinued because
of presumed developing tardive dyskinesias.
Subsequently, she had long-term risperidone (2 mg
per day) that was considered of some effect also.
Mrs A intermittently had antabuse and likewise, for
periods, she received chlorprothixene and different
tranquilizers. Discharge diagnoses were PPD, reactive
psychosis and ‘mixed anxiety’ (ICD 8 and 10). Until
the psychiatric admission, she had moved nine times,
Copyright © 2013 John Wiley & Sons, Ltd.
yet afterwards, she settled down. She succeeded to
finish a short cycle higher education and was in em-
ployment for a few years but was finally fired because
of difficulties in cooperation with colleagues. Then,
an application was produced for premature
retirement.
Discussion
A case is presented in which dominant signs indic-
ative of PPD occurred together with a variety of
(‘co-morbid’) features that are not usually thought
representative of PPD but rather belong to other
illness mainly within the schizophrenia spectrum.
There is limited knowledge about co-morbid
illness in PPD. In the past, Oldham et al. (1995)
demonstrated that patients with mood, anxiety and
psychotic disorders have significantly more PPD
traits than patients without these disorders. Anyhow,
only a few patients were diagnosed with PPD; simi-
larly, in those patients, mood, anxiety and psychotic
disorders often co-occurred, although this finding
was not statistically significant.
Lack of participants with a clinically established
diagnosis of PPD is a common setback in the re-
search literature. As mentioned in the Introduction,
PPD may be only rarely encountered in psychiatric
hospitals. Moreover, as maintained by Skodol et al.
(2011), controversies sometimes arise when diagnos-
ing PPD according to current categorical criteria.
Distrust and concomitant behaviours are present
among various disorders, and some studies based
upon SCID-II (Structured Clinical Interview for
DSM-IV Axis II Personality Disorders) respectively
MCMI-III (Millon Clinical Multiaxial Inventory-
III) have added support in favour of considering
PPD within a dimensional context (Arntz et al.,
2009; Rossi, Elklit, & Simonsen, 2010) rather than
as merely one diagnostic category. In connection
with the recent proposals for the DSM-V, Skodol
et al. (2011) have taken it further and, although they
maintain that ‘(PPD) is one of the most common
PDs in the community…’, even abandon the person-
ality disorder nomenclature being represented by any
specific paranoid personality dimension. Likewise,
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the first proposals of the 11th revision of the ICD
(see Tyrer et al., 2011) introduce a little paradigm
shift. Much emphasis is put on the difficult task to
assess personality disturbance severity, yet room
seems only left for PPD to be ‘accommodated’ into
the patchwork of newly constructed ‘asocial’ and
‘dyssocial’ domains. The particular scientific discov-
eries lying behind the rather non-incremental
break-up of, e.g. the territory of PPD may not appear
exceedingly clear. It must be admitted that PPD have
had difficulties to show empirical data that might
guarantee its status as a clinical diagnosis (Simonsen,
2005). But even though PPD could be described in
terms of a ‘dead’ entity, it does not necessarily desig-
nate a scientific consensus on its abrogation but
rather reflects a simple scarcity of research (Parnas,
Licht, & Bovet, 2005); in accordance with the
traditions of clinical psychiatric practice and endur-
ing—however limited—empirical research, there
seem to be grounds for expressly diagnosing a
paranoid type of character in some instances.
Indeed, in other patients, the appearance of
psychopathological symptoms connects closer to
neighbouring disorders and especially the schizo-
phrenia spectrum. In the case presented here, from
a psychotic illness perspective, the distrust and suspi-
ciousness could be claimed to mirror a downright
schizophrenic process (cf. Simonsen et al., 2008).
In this regard, it remains uncertain from the chart
notes whether development into, e.g. schizophrenia,
was ever suspected, yet every one of accompanying
symptoms was unceasingly concluded marginal and
inconsequential per se. During the entire psychiatric
course, the signs of distrust and suspiciousness were
judged by the psychiatric specialists to constitute
the most marked and invariant elements of the
disease picture together with the tense and guarded
attitude and struggles in social life. Even so, a number
of ‘classical’ PPD traits were not present. Neither was
any exquisite sensitivity mentioned in the chart
notes, nor was self-reference, bearing grudge,
concern about conspiracies or pathological jealousy.
From the point of view of personality disorder
syndromes, the signs of distrust and suspiciousness
were left alone, so to speak; there happened to be
Copyright © 2013 John Wiley & Sons, Ltd.
Complex paranoid personality case 257
remarkably little ‘matter’ behind. When confronting
the distrustful attitude, there were no long-winded
explanations, no far-out excuses, no opinionated
accusations, no brooding anger and nothing but a
diffuse antagonism and anxiety. In PPD, we might
expect the patient’s distrustful attitude to constitute
an all-encompassing trait tightly connected to
mighty bastions of the latter mentioned indicators
of a distinctively disordered personality: confronting
the mental health-care worker with either harsh
rejection or recruitment as ‘the solitary allied’.
Questions:
(1) Does Mrs A suffer from PPD?
(2) Should we expect to occasionally find slight for-
mal thought disorder, subtle self-disorder and
the like in PPD or its diagnostic successors?
(3) Might Mrs A rather have been diagnosed with, e.
g., schizotypal disorder or a paranoid schizophrenia?
(4) Precise diagnosis of Mrs A—does it matter at
all (e.g. treatment)?
Conflict of interest
None.
Acknowledgement
The author would like to thank the head of the
Department of Psychiatry of Svendborg Hospital,
Gunnar Jessen MD, for placing at disposal the
records archives of the institution.
References
American Psychiatric Association, APA. (2000). Diagnostic
and statistical manual of mental disorders, 4th edition, text
revision: DSM-IV-TR. Washington, DC: American Psy-
chiatric Association.
Arntz, A., Bernstein, D., Gielen, D., van Nieuwenhuyzen,
M., Penders, K., Haslam, N., & Ruscio, J. (2009).
Taxometric evidence for the dimensional structure of
cluster-C, paranoid, and borderline personality disorders.
Journal of Personality Disorders, 23, 606–628.
7: 254–258 (2013)
DOI: 10.1002/pmh
258 Birkeland
Birkeland, S. F. (2011). Paranoid personality disorder and
sociodemography: a 25-year study of first admissions to a
Danish general psychiatric hospital. Nordic Psychology,
63, 40–49.
Fulton, M., & Winokur, G. (1993). A comparative study of
paranoid and schizoid personality disorders. American
Journal of Psychiatry, 150, 1363–1367.
Meyer, A. (1903). An attempt at analysis of the neurotic con-
stitution. American Journal of Psychology, XIV, 354–367.
Nirestean, A., Lukacs, E., Cimpan, D., & Taran, L. (2012).
Complex case: schizoid personality disorder—the pecu-
liarities of their interpersonal relationships and existential
roles. Personality and Mental Health, 6, 69–74.
Oldham, J. M., Skodol, A. E., Kellmann, H. D., Hyler, S. E.,
Doidge, N., Rosnick, L., & Gallaher, P. E. (1995). Co-
morbidity of axis I and axis II disorders. American Journal
of Psychiatry, 152, 571–578.
Ottoson, H., Ekselius, L., Grann, M., & Kullgren, G. (2002).
Cross-system concordance of personality disorder diagno-
ses of DSM-IV and diagnostic criteria for research of ICD-
10. Journal of Personality Disorders, 16, 283–292.
Parnas, J., Licht, D., & Bovet, P. (2005). Cluster a personality dis-
orders: a review. In M. Maj, H. S. Akiskal, J. E. Mezzich, &
A. Okasha (Eds.), Personality disorders. New York: John
Wiley & Sons.
Raballo, A., & Parnas, J. (2011). The silent side of the spec-
trum: schizotypy and the schizotaxic self. Schizophrenia
Bulletin, 37, 1017–1026.
Rossi, G., Elklit, A., & Simonsen, E. (2010). Empirical evi-
dence for a four factor framework of personality disorder
organization: multigroup confirmatory factor analysis of
the Millon Clinical Multiaxial Inventory-III personality
disorder scales across Belgian and Danish data samples.
Journal of Personality Disorders, 24, 128–150.
Simonsen, E. (2005). Changing boundaries at different levels of
validity. In M. Maj, H. S. Akiskal, J. E. Mezzich, & A. Okasha
(Eds.), Personality disorders. New York: John Wiley & Sons.
Simonsen, E., Haahr, U., Mortensen, E. L., Friis, S.,
Johannessen, J. O., Larsen, T. K., Melle, I., Opjordsmoen,
Copyright © 2013 John Wiley & Sons, Ltd.
S., Rund, B. R., McGlashan, T., & Vaglum, P. (2008).
Personality disorders in first-episode psychosis. Personality
and Mental Health, 2, 230–239.
Skodol, A. E., Bender, D. S., Morey, L. C., Clark, L. A.,
Oldham, J. M., Alarcon, R. D., Krueger, R. F., Verheul, R.,
Bell, C. C., & Siever, L. J. (2011). Personality disorder
types proposed for DSM-5. Journal of Personality Disor-
ders, 25, 136–169.
Thompson-Pope, S. K., & Turkat, I. D. (1993). Schizotypal,
schizoid, paranoid, and avoidant personality disorders. In
P. B. Sutker, & H. E. Adams (Eds.), Comprehensive hand-
book of psychopathology (2nd ed.). New York and London:
Plenum Press.
Tienari, P., Wynne, L. C., Läksy, K., Moring, J., Nieminen,
P., Sorri, A., Lahti, I., & Wahlberg, K. E. (2003). Genetic
boundaries of the schizophrenia spectrum: evidence from
the Finnish adoptive family study of schizophrenia. Amer-
ican Journal of Psychiatry, 160, 1587–1594.
Torgersen, S., Kringlen, E., & Cramer, V. (2001). The prev-
alence of personality disorders in a community sample.
Archives of General Psychiatry, 58, 590–596.
Tyrer, P., Mitchard, S., Methuen, C., & Ranger, M. (2003).
Treatment rejecting and treatment seeking personality disor-
ders: type R and type S. Journal of Personality Disorders, 3,
263–268.
Tyrer, P., Crawford, M., Mulder, R., Blashfield, R., Farnam, A.,
Fossati, A., Kim, Y.-R., Koldobsky, N., Lecic-Tosevski, D.,
Ndetei, D., Swales, M., Clark, L. A., & Reed, G. M.
(2011). The rationale for the reclassification of personality
disorder in the 11th revision of the International Classifica-
tion of Diseases (ICD-11). Personality and Mental Health, 5,
246–259.
WHO. (1993). Classification of mental and behavioural disorders.
Diagnostic criteria for research: ICD-10. Geneva: World
Health Organization.
Address correspondence to: Søren Fryd Birkeland
MD, Vaengevej 22, DK-5772 Kvaerndrup, Denmark.
Email soeren@birkeland.dk
7: 254–258 (2013)
DOI: 10.1002/pmh