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

When the Others Are Dangerous: Paranoid Presentations in Subclinical Forms of Personality Disorders

The discriminant validity of paranoid personality disorder has been recently questioned, and paranoid presentations are now conceived of as transdiagnostic features of personality disorders (PDs). However, empirical results are inconsistent. This study investigated the link between subclinical personality disorders (except paranoid PD) and paranoid presentations, exploring how the severity of personality functioning affects this relationship. Nonclinical participants (N = 270, females: n = 194; 71.9%) completed self-report measures of the constructs of interest. In multiple regression analyses, subclinical borderline PD was primarily related to a wide range of paranoid presentations. Moreover, the severity of personality functioning increased the strength of the association between subclinical BPD and severe paranoid presentations. Results suggest that, when exploring unique contributions, paranoid presentations are especially associated with subclinical forms of BPD and highlight the importance of considering personality dysfunction severity. Additionally, the findings demonstrate that paranoid presentations are a relatively transdiagnostic dimension.

Digitally Enhanced Psychological Assessment and Treatment of Paranoia: A Systematic Review

BACKGROUND

Paranoia is relatively common but can lead to significant distress, impairment and need for care. Digital technologies offer a valuable extension to service provision and are increasingly being integrated into healthcare. This systematic review evaluated feasibility, acceptability, and effectiveness of digitally enhanced psychological assessments and treatments for paranoia across the paranoia continuum (PROSPERO: CRD42023393257).

METHODS

Databases PsychINFO, EMBASE, MEDLINE and Web of Science were searched until 12 June 2023; the Effective Public Health Practice Project (EPHPP) quality assessment tool evaluated studies; and a narrative synthesis was conducted.

RESULTS

Twenty-seven studies met inclusion criteria (n = 3457, 23 assessment and 4 treatment, 2005-2023, most in Europe). Technologies included virtual reality (VR, n = 23), experience sampling methodology (ESM, n = 2), an app (n = 1) and a combination of VR and ESM (n = 1). Assessments involved monitoring paranoia under various virtual conditions or in everyday life. Treatments were generally integrated with Cognitive Behaviour Therapy (CBT), which involved using VR to test out threat beliefs and drop safety behaviours or using an app to support slowing down paranoid thinking. EPHPP ratings were strong (n = 8), moderate (n = 12) and weak (n = 7).

CONCLUSIONS

Digitally enhanced assessments and treatments showed promising acceptability, feasibility and treatment effectiveness. Limitations of studies include small sample sizes, lack of comparison groups and long-term data and limited randomised controlled trials. Results support the potential future integration of VR in the assessment of paranoia and show promise for treatments such as CBT, although further clinical trials are required. Investigation of other technologies is limited.

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

Unlike internalizing and externalizing symptoms, psychotic symptoms (e.g., hallucinations, delusions) are manifestations of personality disorders (PDs) that are more controversial and poorly understood. This leaves clinicians with very little guidance for clinical practice, especially for diagnosis. What is more, most reviews have focused strictly on the links between psychotic symptoms and the categorically defined borderline PD, which contrasts with the growing movement that emphasizes a dimensional perspective (especially in psychology). Thus, the objectives of this critical review will be to (a) expose typical cases where PDs and psychotic symptoms might cooccur; (b) assess the state of scientific knowledge surrounding PD and psychotic symptoms; and (c) provide clinicians and researchers with recommendations to keep the field moving forward. We conclude that researchers and clinicians should move past the false "PD or psychosis" dichotomy since they often cooccur, avoid (as far as possible) making psychotic symptoms an exclusion criterion in PD research to enhance ecological validity, and consider dimensional PD diagnosis as a potential unifying solution to the dilemma posed by this cooccurrence.