Short communication 283
Psychopharmacological treatment and course in paranoid
personality disorder: a case series
Søren F. Birkeland
Little is known about the role of psychopharmacological
treatment and course of illness in patients diagnosed with
a paranoid personality disorder. This short communication
provides a naturalistic study of a psychiatric hospital case
series. Fifteen consecutive patients were retrospectively
studied. The Clinical Global Impression was rated at first
c 2013
admission, at last psychiatric contact, and after a 6-week
observation period with or without antipsychotic treatment.
During psychiatric admissions, three patients improved
markedly, eight showed only minor changes, and four
worsened. In total, seven patients had been administered
any antipsychotic medication. The median duration of
treatment was 15 weeks (range 4 days–328 weeks). No
major adverse effects were noted. Among patients with
sixth-week observations available, four had received
antipsychotics; they appeared to improve considerably
Introduction
Recent advances in treatments for personality disorders
have focused on borderline personality disorder in
particular (Schmahl et al., 2012). By way of comparison,
the management of personality disorders with predomi-
nant paranoid symptoms has received only scant research
attention. Traditionally, paranoid personality disorder
(PPD) has been characterized by the presence of traits
such as hypersensitivity, distrust, and jealousy. Study
recruitment of patients with such traits is particularly
difficult and therefore empirical research is very limited
(Thompson-Pope and Turkat, 1993; Parnas et al., 2005).
This short communication presents a naturalistic study
of the psychopharmacological treatment and course of
illness in a Danish case series.
Case series
The charts of 15 consecutive patients diagnosed with
PPD in a general psychiatric hospital were retrospectively
assessed; the method of patient inclusion and data
collection has been described previously (Birkeland,
2011). Clinical Global Impression (CGI) (Guy, 1976)
was rated at first admission, CGI-S (severity), and last
psychiatric contact, CGI-I (improvement), together with
the course of psychopharmacological treatment and
additional interventions. The reasons for discontinuation
were recorded. An open-label cohort study was carried
out: if obtainable, a CGI-I rating was applied at the first
6-week psychiatric observation period either with or
without antipsychotic medication. The 6-week juncture
was chosen because antipsychotics should be manifestly
0268-1315
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compared with six patients who had not received
antipsychotics. Although the findings should be interpreted
with caution, they support the notion of the disorder being
a relatively chronic condition, although antipsychotics
appeared to be safe and possibly had an effect in the short
term. Int Clin Psychopharmacol 28:283–285
Wolters Kluwer Health | Lippincott Williams & Wilkins.
International Clinical Psychopharmacology 2013, 28:283–285
Keywords: antipsychotics, paranoid personality disorder, schizophrenia
Department of Psychiatry, Svendborg Hospital, Denmark
Correspondence to Søren F. Birkeland, MD, Vaengevej 22, Kvaerndrup DK-5772,
Denmark
Tel: + 45 606 04349; e-mail: soeren@birkeland.dk
Received 28 February 2013 Accepted 6 June 2013
effective in most patients within this time frame. Also,
this juncture might sort out temporary changes and
effects. Patients were considered to have continued
taking a medication if they were in hospital or maintained
their visits to the clinic and discontinuation was not
suspected. Finally, adverse effects and other treatment
modalities were noted. Ordinal variables were analyzed
using the Mann–Whitney U-test. The level of statistical
significance was set at P value less than 0.05, two-tailed.
At first psychiatric admission, three patients were
‘moderately ill’ (CGI-S 4), nine were ‘markedly ill’
(CGI-S 5), and three were ‘severely ill’ (CGI-S 6); the
median patient age was 42 years. At last psychiatric
contact, the median age was 50 years: three patients were
‘much’ improved (CGI-I 2), eight showed only minor
changes (CGI-I 3–5), and four were ‘much’ or ‘very much’
worsened (CGI-I 6 and 7).
One patient developed alcohol abuse. One patient was
suspected of developing schizophrenia and died before
the age of 40, two died in their 60s, and one died aged
older than 70 years. Among the patients alive, one was
older than 80 years of age.
In total, seven patients had been administered antipsycho-
tic drugs (most frequently flupentixol). The median
duration of treatment was 15 weeks (range 4 days–328
weeks). Three patients reported sedation, resulting in
discontinuation in one. One reported restlessness and one
who received bromperidol additionally reported rigidity,
‘feelings of indifference’, and ‘diminished initiative’ and
DOI: 10.1097/YIC.0b013e328363f676
284 International Clinical Psychopharmacology 2013, Vol 28 No 5
therefore discontinued. Psychiatric hospital admission was
unavoidable in five patients receiving antipsychotics.
Five patients were lost to 6-week observations (CGI-S,
range 4–5, median 5, mean 4.8), whereas data were
obtainable from ten: four had received antipsychotics (three
men, one woman; median CGI-S 5.5, range 5–6, mean 5.5;
bromperidol 2 mg/day, promazine 50 mg/day, and flupentixol
2 and 3 mg/day; no suspicion of noncompliance) and the
rest (four men and two women; median CGI-S 5, range 4–6,
mean 4.8) had not. In terms of therapeutic effects,
all patients in the antipsychotics group had improved much
or very much (CGI-I, range 1–2, median 2, mean 1.8)
compared with improvement in only two patients and
unchanged or worsened status in the remaining four
patients in the nonantipsychotics group (CGI-I, range
2–5, median 4.5, mean 4.0; P < 0.05, Mann–Whitney
U-test, two-tailed). At last psychiatric contact, one patient
in the antipsychotics group was much improved, two were
minimally improved, and one was much worsened. Beyond
the 6-week follow-up, antidepressives had been adminis-
tered in seven patients; a beneficial effect (decrease in
depression symptom) was recorded in only three patients
and typically following 1 month of treatment.
Seven patients received a more or less well-defined
psychosocial intervention (mostly group and milieu therapy)
that was considered somewhat beneficial in five. One
patient received meprobamate and seven patients occa-
sionally used benzodiazepines; there was no information on
effects but at least one patient developed abuse.
Discussion
In this naturalistic open-label study, the presentation of
PPD tended to be chronic while 6 weeks of antipsychotic
treatment seemed to relieve symptoms with no major
adverse effects.
The study presupposes that sound information on the
dynamics of patients’ status can be read from charts.
However, in addition to the small sample size, resulting in a
statistical power of just below 0.5 to detect even major
group differences, the assessment of antipsychotic effects
lacks a randomized, blinded, assignment. Outcomes, there-
fore, can be biased by, for example, confounding by
indication because of baseline and time-dependent factors
that are not accounted for. Baseline CGI-S ratings indicate
that the group that received antipsychotics may have had
(slightly) more severe illness than those who received no
antipsychotics. It remains, however, unclear to what extent
any such difference and, for example, ‘naturally occurring
fluctuations’ in severity of illness can explain the compara-
tively large dissimilarity in CGI-I ratings.
The course of illness in patients with PPD has received
only scant attention in the literature. In the past, the
longitudinal course was investigated retrospectively in 19
patients by Fulton and Winokur (1993). They succeeded
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
in obtaining follow-up information by letter or personal
interview in only seven patients: in these patients, no
evident clinical change could be found. The present
results seem to be in agreement with these earlier
findings.
In terms of the usefulness of psychopharmacological
treatment in personality disorders, empirical research has
been increasing. Previously, on the basis of the charts of
10 patients, olanzapine was concluded to be beneficial in
cluster B personality disorders (Zullino et al., 2002) and
afterwards, in a small 8-week open-label trial, quetiapine
induced significant improvements in borderline person-
ality disorder (Adityanjee et al., 2008). More recently,
naltrexone showed promising effects in the management of
borderline personality disorder in a small randomized-
controlled trial, although statistical significance was not
reached (Schmahl et al., 2012). Continuously, there has been
a lack of research on psychopharmacologic use in PPD.
When viewed from this background, the findings in this
study seem convincing and apparently are in accordance
with the advice by Siever and Kendler (1985) that such
patients sometimes benefit from low doses of neuroleptic
medication. In any case, the findings suggest that the
impact of antipsychotic treatment was not definite. Within
the ‘naturalistic’ settings, only a minority of patients
received a durable medication. Likewise, the requirement
of readmissions was not efficiently prevented and last-
contact improvement ratings did not impressively show that
antipsychotics affected the long-term prognosis. Moreover,
the study shows that other treatment modalities may come
into play as well.
Conclusion
Although the findings should be interpreted with caution,
they support the notion that personality disorder of
paranoid type tends to follow a chronic course, whereas,
in the short run, antipsychotic treatment may perhaps be
safe and effective. In any case, appropriately controlled
studies are required to ascertain the role of pharmacolo-
gical and nonpharmacological interventions for patients
with this kind of disorder.
Acknowledgements
Thanks are due to Gunnar Jessen, MD, the head of the
Department of Psychiatry, Svendborg Hospital, who
placed the records archives at disposal.
Conflicts of interest
There are no conflicts of interest.
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