In search of hidden threats: A scoping review on paranoid presentations in personality disorders

Abstract

Recent diagnostic developments suggest that paranoia is a transdiagnostic characteristic common to several personality disorders rather than a personality disorder per se. Nonetheless, empirical literature fails to provide comprehensive and univocal findings on whether and how paranoid presentations relate to different personality disorders. In the present scoping review, we map the empirical literature on paranoid presentations in personality disorders, considering the entire spectrum of paranoid manifestations (i.e., the paranoia hierarchy). In selecting original quantitative studies on paranoid presentations in personality‐disordered patients, we screened 4,433 records in PsycArticles, PsycInfo and PUBMED. We eventually included 47 eligible studies in the review. Our synthesis indicates consistent empirical evidence of a wide range of paranoid presentations in Paranoid, Schizotypal and Borderline personality disorders. Conversely, little empirical literature exists on paranoid presentations in other personality disorders. Preliminary findings suggest broad‐severity paranoid presentations, ranging from milder to severe forms, in Paranoid, Schizotypal and Borderline personality disorders. There is also some evidence of milder forms of paranoia in Avoidant, Antisocial and Narcissistic personality disorders. Conversely, there is poor evidence of paranoid presentations in Schizoid, Histrionic, Dependent or Obsessive‐compulsive personality disorders. Research gaps and recommendations for improving empirical research on paranoid presentations in personality disorders are discussed.

Time to put aside the false dichotomy between personality disorders and psychotic symptoms

“…Paranoid and schizoid PDs are special cases because, despite their long history, there is a paucity of empirical research on those disorders, possibly stemming in part from the practical difficulty in recruiting such patients (Fanti et al, 2023; Triebwasser et al, 2013). Those limited evidence bases also led to their removal in the DSM‐5‐TR Alternative Model for Personality Disorders (American Psychiatric Association, 2022); it is suggested that they might be better construed as subtypes/cooccurrences of other PDs or be captured by the new trait‐specified PD (e.g., with traits such as Intimacy Avoidance, Suspiciousness, or Withdrawal; Skodol et al, 2011).…”

“…Nevertheless, the transdiagnostic concept of paranoia (the attribution of malevolent/hostile intents to others) might still bear relevance for the broader spectrum of PDs. Indeed, it can be a feature of virtually all categorical PDs (e.g., borderline, histrionic, obsessive‐compulsive) and many “syndromic” disorders (e.g., depression, posttraumatic stress disorder; Fanti et al, 2023). The paranoia continuum, while calling for more research, might be a mechanism linking personality to psychosis by spanning a wide range of nonpsychotic and psychotic experiences (ranging from, e.g., fear of rejection to ideas of reference and persecution; Fanti et al, 2023).…”

Recent advances in research on personality disorders

“…Results of a systematic review of Fanti et al (2023) revealed that paranoia may be transdiagnostic in a variety of personality disorder diagnoses. They found evidence of mild-to-severe paranoia not only in paranoid personality disorder and schizotypal personality disorder but also in borderline personality disorder as well.…”