Some behaviors that are inﬂuenced by sociocultural contexts or specific life circumstances may be erroneously labeled paranoid and may even be reinforced by the process of clinical evaluation. Members of minority groups, immigrants, political and economic refugees, or individuals of different ethnic backgrounds may display guarded or defensive behaviors because of unfamiliarity (e.g., language barriers or lack of knowledge of rules and regula- tions) or in response to the perceived neglect or indifference of the majority society. These behaviors can, in turn, generate anger and frustration in those who deal with these indi- viduals, thus setting up a vicious cycle of mutual mistrust, which should not be confused with paranoid personality disorder. Some ethnic groups also display culturally related be- haviors that can be misinterpreted as paranoid.
Other mental disorders with psychotic symptoms. Paranoid personality disorder can be distinguished from delusional disorder, persecutory type; schizophrenia; and a bipolar or depressive disorder with psychotic features because these disorders are all characterized by a period of persistent psychotic symptoms (e.g., delusions and hallucinations). For an additional diagnosis of paranoid personality disorder to be given, the personality disorder must have been present before the onset of psychotic symptoms and must persist when the psychotic symptoms are in remission. When an individual has another persistent mental disorder (e.g., schizophrenia) that was preceded by paranoid personality disorder, paranoid personality dis- order should also be recorded, followed by ”premorbid” in parentheses.
Personality change due to another medical condition. Paranoid personality disorder must be distinguished from personality change due to another medical condition, in which the traits that emerge are attributable to the direct effects of another medical condi- tion on the central nervous system.
Substance use disorders. Paranoid personality disorder must be distinguished from symptoms that may develop in association with persistent substance use.
Paranoid traits associated with physical handicaps. The disorder must also be distin- guished from paranoid traits associated with the development of physical handicaps (e.g., a hearing impairment).
Other personality disorders and personality traits. Other personality disorders may be confused with paranoid personality disorder because they have certain features in common.
It is therefore important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to paranoid personality disorder, all can be diagnosed. Paranoid personality disorder and schizotypal personality disorder share the traits of suspiciousness, interpersonal aloofness, and paranoid ideation, but schizotypal per- sonality disorder also includes symptoms such as magical thinking, unusual perceptual ex- periences, and odd thinking and speech. Individuals with behaviors that meet criteria for schizoid personality disorder are often perceived as strange, eccentric, cold, and aloof, but they do not usually have prominent paranoid ideation. The tendency of individuals with paranoid personality disorder to react to minor stimuli with anger is also seen in borderline and histrionic personality disorders. However, these disorders are not necessarily associ- ated with pervasive suspiciousness. People with avoidant personality disorder may also be reluctant to confide in others, but more from fear of being embarrassed or found inadequate than from fear of others’ malicious intent. Although antisocial behavior may be present in some individuals with paranoid personality disorder, it is not usually motivated by a desire for personal gain or to exploit others as in antisocial personality disorder, but rather is more often attributable to a desire for revenge. Individuals with narcissistic personality disorder may occasionally display suspiciousness, social withdrawal, or alienation, but this derives primarily from fears of having their imperfections or ﬂaws revealed.