Section Learning Objectives

• Describe the symptoms associated with each cluster A personality disorder.
• Describe the epidemiology of cluster A personality disorders.
• Describe the treatments for cluster A personality disorders.

9.2.1 Clinical Descriptions

9.2.1.1 Paranoid Personality Disorder

Paranoid personality disorder is characterized by a severe distrust or suspicion of others. Individuals interpret and believe that others’ motives and interactions are intended to harm them, and therefore, they are skeptical about establishing close relationships outside of family members — although at times even family members’ actions are believed to be malevolent (APA, 2022). Individuals with paranoid personality disorder often feel as though they have been deeply and irreversibly hurt by others even though there is little to no evidence to support that others intended to, or actually did, cause them harm. Because of these persistent suspicions, they will doubt relationships that show true loyalty or trustworthiness.

Individuals with paranoid personality disorder are also hesitant to share any personal information or confide in others as they fear the information will be used against them (APA, 2022). Additionally, benign remarks or events are often interpreted as demeaning or threatening. For example, if an individual with paranoid personality disorder was accidentally bumped into at the store, they would interpret this action as intentional, with the purpose of causing them injury. Because of this, individuals with paranoid personality disorder are quick to hold grudges and unwilling to forgive perceived insults or injuries – whether intentional or not (APA, 2022). They are known to quickly, and angrily counterattack either verbally or physically in situations where they feel they were insulted or otherwise harmed.

9.2.1.2 Schizoid Personality Disorder

Individuals with schizoid personality disorder display a persistent pattern of avoidance of social relationships along with a limited range of emotions in social relationships (APA, 2013). Similar to those with paranoid personality disorder, individuals with schizoid personality disorder do not have many close relationships; however, unlike paranoid personality disorder, this lack of relationship is not due to suspicious feelings, but rather, the lack of desire to engage with others and the preference to engage in solitary behaviors. Individuals with schizoid personality disorder are often viewed as “loners” and prefer activities where they do not have to engage with others (APA, 2022). Established relationships rarely extend outside the family as those diagnosed with schizoid personality disorder make no effort to develop or maintain friendships. This lack of establishing social relationships also extends to sexual behaviors, as those with schizoid personality disorder report a lack of interest in engaging in sexual experiences with others.

With regard to the limited range of emotion, individuals with schizoid personality disorder are often indifferent to criticisms or praises of others and appear to not be affected by what others think of them (APA, 2022). They will rarely show any feelings or expressions of emotions and are often described as having a “bland” exterior (APA, 2022). In fact, individuals with schizoid personality disorder rarely reciprocate facial expressions or gestures typically displayed in normal conversations such as smiles or nods.

9.2.1.3 Schizotypal Personality Disorder

Schizotypal personality disorder is characterized by a range of impairments in social and interpersonal relationships due to discomfort in relationships, along with odd cognitive and/or perceptual distortions and eccentric behaviors (APA, 2022). Similar to those with schizoid personality disorder, individuals with schizotypal personality disorder have few, if any established relationships outside of family members.

One of the most prominent features of schizotypal personality disorder is ideas of reference or the belief that unrelated events pertain to them in a particular and unusual way. This is a milder version of the delusions of reference that were discussed in the previous chapter. Ideas of reference also lead to superstitious behaviors or preoccupation with paranormal activities and individuals with this disorder may believe they have special or magical powers such as the ability to mind-read or control other’s thoughts. Unusual perceptual experiences such as sensing the presence of another person or hearing one’s name (subthreshold hallucinations), as well as unusual speech patterns such as derailment or incoherence are also symptoms of this disorder. Generally speaking, individuals with this disorder often act or appear odd, eccentric, or peculiar (APA, 2022).

Similar to the other cluster A personality disorders, there is also a component of paranoia or suspiciousness of others’ motives in schizotypal personality disorder. Additionally, individuals with this disorder also display inappropriate or restricted affect, thus impacting their ability to appropriately interact with others in a social context. Significant social anxiety is often also present, however, their social anxiety is typically driven by paranoid fears rather than concerns about being negatively evaluated or judged as is typically reported by individuals with social anxiety disorder. As such, individuals with schizotypal personality disorder also have difficulty establishing and maintaining personal relationships other than first-degree relatives.

9.2.2 Epidemiology

Cluster A personality disorders have a prevalence rate of around 3.6% (APA, 2022). More specifically, paranoid personality disorder is estimated to affect approximately 3.2% of the general population (APA, 2022). Schizoid personality disorder is estimated to occur in approximately 1.3% of the general population, whereas the prevalence rate for schizotypal personality disorder is 0.6% (APA, 2022). It is unclear whether men or women are more likely to be diagnosed with paranoid personality disorder and schizoid personality disorder, but schizotypal personality disorder does appear to be more commonly diagnosed in men (APA, 2022).

Note: Due to the overlap among comorbidities and etiological factors we will reserve our discussion of those until the end of the chapter and will proceed directly to the treatment of the cluster A personality disorders.

9.2.3 Treatment

Individuals diagnosed with a cluster A personality disorder often do not seek out treatment as they do not identify themselves as someone who needs help (Millon, 2011). Of those that do seek treatment, the majority do not enter it willingly. Furthermore, due to the nature of these disorders, individuals in treatment often struggle to trust the clinician as they are suspicious of the clinician’s intentions (paranoid and schizotypal personality disorder) or are emotionally distant from the clinician as they do not have a desire to engage in treatment due to a lack of overall emotion and desire for relationships (schizoid personality disorder; Kellett & Hardy, 2014, Colli, Tanzilli, Dimaggio, & Lingiardi, 2014). Because of this, treatment is known to move very slowly, with many clients dropping out of treatment before symptoms are resolved.

When clients are enrolled in treatment, cognitive behavioral strategies are most commonly used with the primary intention of reducing anxiety-related symptoms. Additionally, attempts at cognitive restructuring – both identifying and changing maladaptive thought patterns – are also helpful in addressing the misinterpretations of others’ words and actions, particularly in those with paranoid personality disorder (Kellett & Hardy, 2014). Clients with schizoid personality disorder may be engaged in CBT techniques to help them experience more positive emotions and engage in more satisfying social experiences; whereas the goal of CBT for schizotypal personality disorder is to evaluate unusual thoughts or perceptions objectively and to ignore inappropriate or distorted thoughts (Beck & Weishaar, 2011). Finally, behavioral techniques such as social-skills training may also be implemented to address ongoing interpersonal problems characteristic of these disorders.