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Dependent on alcohol and have 301.0 paranoid personality disorder. Proper diagnosis and cure?

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Part 3
XXXXXXX, 25, works as a draftsman for a large architectural design firm. It is a fairly solitary job. He’s come to see you because, “My boss told me to get help, or else. Bottom line: He wants to fire me, but his boss, my uncle, won’t let him.” He smiles and says, “It’s good to know people in high places.”

XXXXXXX physician also referred him, and has sent you XXXXXXX previous treatment records (Parts 1 and 2), which indicate no significant medical concerns. You ask why he thinks his boss wants to fire him and are told, “He’s always making jokes about me behind my back. I hear ‘em all laughing. I’m his star draftsman, but he doesn’t pay me what I’m worth. I’m sure he pays the others more than he pays me, not that they’ll say boo about that. They have kind of a pact, I think, to keep stuff like that from me. And my boss only gives me compliments to get me to work harder. He’s not fooling me. Neither are the others. They’re jealous because of my uncle and . . . other things. You know the kind of stuff I mean.”

You ask him to tell you more. He frowns at you, stares, then shakes his head. “You’re in on this, aren’t you!?” He laughs. “Sure. I see it now. He gives me the names of three therapists and tells me to see one. Smart. I’ll bet he paid the three of you to do what he wants. You all knew I was coming to one of you! To think I was dumb enough to believe that with three names to choose from this had to be on the up-and-up.” He shakes his head. “Jeez!”

You explain that you don’t know his boss. “Yeah,” XXXXXXX says, “I believe you. Now, I suppose you’ve got a bridge to sell me.” You explain that he is welcome to choose any therapist he wants, and that if he prefers to end the session he is free to choose another therapist. “Sure,” he says, “so you can tell my boss I walked out, and he still gets me to work with someone in his pocket. I’m not falling for that. I’m here. I’ll work with you. He said I needed therapy and my uncle went along with it. So, I’m getting therapy. I’m not playing my boss’s game. But I don’t want you sending him any little messages about what we talk about.” You agree that everything you talk about will be confidential unless (in the spirit of informed consent) there’s a potential XXXXXXX could harm himself or someone else. “Did he tell you I was a danger to him?” he asks. “Is that what this is about? You can’t trust the man. He’ll say anything to get his way.” You reiterate that you have never spoken with his boss.

In a few minutes, he calms down and asks, “So what do we do in this so-called ‘therapy’?” You suggest that he tell you about himself, maybe what his boss is concerned about, or what he (XXXXXXX ) might want help with. After another discussion about confidentiality, he insists that you to sign a note stating that you will not reveal anything to anyone about what he says unless it’s about hurting himself or someone else, “Because I’m not going to hurt anyone unless they try to get me first.” You sign the agreement. Only then does he begin to talk about himself, after insisting, “I don’t want you writing all this down. And if you break our agreement, I’ll XXXXXXX you. I will. Believe me.”

You ask about his earlier emotional issues and the event with his father’s revolver, which you read in the records. “I’m not depressed, if that’s what you’re thinking. I like everyone and everything, I just don’t trust ‘em,” he says. “I’m happy. I sleep fine. I’m not losing weight. I’m not here for happy pills. I’m just here to find out how to get my boss off my back.” He smirks. “And, maybe, how to know if my partner is having an affair. I’ve never been able to prove anything, but . . . I know he is, and he gives me signs all the time. I just haven’t caught him at it.”

XXXXXXX is reluctant to talk about himself, but eventually answers some questions after making you explain why you are asking each one. You learn that he drinks three to five highballs a day on weekends, “sometimes more, lots more once in awhile,” and that he has ongoing trouble with his family of origin, whom, he says, “tried to hold him hostage” to old country ways. He tells you his parents don’t understand him and are always “snooping” into his life, which is why he changes his cell phone every couple of months.

“Besides,” he adds sarcastically, “There are no XXXXXXX Muslims, you know. My dad tells me that all the time.” He wags his head. “Hell, almost everyone at the firm is XXXXXXX and we come from all over the world. What’s he think—that Allah only makes Christians and atheists gay?”

1.     What are your diagnostic hypotheses for XXXXXXX in this scenario?
Here is my diagnosis…

AXIS I:          799.9 Alcohol Dependence (Pending)
AXIS II:     301.0     Paranoid Personality Disorder
AXIS III:     None
AXIS IV:     Work, Social, Family
AXIS V:     70

2.     Describe what further diagnostic information you need (what further diagnostic evaluation is warranted).

It is evident that XXXXXXX was raised by a fairly traditional Pakistani Muslim Family and he has embraced the Western cultural ideas. As a result, it would be good to complete a psychosocial in addition the MMPI. As far as the alcohol, I would administer the SASSI 3. Anything else?

3.      From a diathesis-stress perspective, what impact do the cultural, ethnic and psychosexual issues have on XXXXXXX and his family in this scenario, and what other issues may play a role?

4. What would be the suggested course of treatment?

Psychotherapy would be the treatment of choice. This will be a therapy which emphasizes a simple supportive, client-centered approach will be most effective. Rapport-building with a person who has this disorder will be much more difficult than usual because of the paranoia associated with the disorder. Any other thoughts?

5 Overall, given XXXXXXX family background and his open homosexuality, what cultural and ethnic factors do you need to be aware of at the different stages of his life, and how would you deal with them in arriving at your diagnoses?

Posted Fri, 21 Dec 2012 in Mental Health
Answered by Dr. Jonas Sundarakumar 26 hours later

1) I agree with your diagnostic hypothesis and XXXXXXX would fulfill the entire set of diagnostic criteria for a paranoid personality disorder, and XXXXXXX would typically fit into the "fanatic paranoid" i.e. paranoid personality with some narcissistic traits. However, for argument's sake, it must also be noted that in this piece of history, there is actually no information which tells you how long XXXXXXX has been having these symptoms... i.e. whether these are long-standing pervasive traits amounting to a personality disorder (most likely) or whether these are well circumscribed and of recent origin, thus raising the possibility of a Delusional disorder. Remember, both these are mutually exclusive diagnoses, which means that one of them can be diagnosed only in the absence of the other.

2) As part of further diagnostic evaluation, I would explore his personality in detail to confirm a diagnosis of a paranoid personality disorder(an MMPI would be appropriate here) and exclude a delusional disorder. Like you have mentioned, an assessment to confirm the diagnosis of alcohol dependence as well as a detailed psychosocial exploration would be appropriate.

3) From a diathesis-stress perspective, environmental stress in the form of being brought up in a different culture, psycho-sexual issues like non-acceptance of his homosexual orientation and the resulting social ostracization, could all be combining with a pre-existing genetic vulnerability to result in XXXXXXX paranoia.

4) If a diagnosis of a Paranoid personality disorder is confirmed, the further treatment would be predominantly psychotherapy, and in some cases additional medication also. As medications are likely to be received with suspicion, the treatment of choice is usually psychotherapy, but this depends on the individual's specific behaviors and willingness to participate in treatment. Psychotherapy is challenging since these people are often very suspicious of doctors and it's difficult to form a meaningful rapport - which is the core of any psychotherapeutic intervention. Therapy and medications should have realistic aims of reducing the paranoia and limiting its impact on the person's daily functioning, rather than expecting a complete cure. Supportive psychotherapy is the treatment of choice, and excessive interpretation by the therapist of XXXXXXX conflicts should be avoided initially, as trust and tolerance of intimacy are difficult to establish. The therapist should be professional, straightforward, and not overly warm. When behavior becomes threatening, limits must be set gently but realistically, without humiliating or frightening the individual. Antipsychotics might be needed briefly for severe agitation or for thinking bordering on delusional.

5) There seem to be two issues which need to be understood here: One is the marked difference in beliefs and attitudes between the culture he has been born in and the culture in which he has been brought up. Secondly, there seem to be a discrepancy between XXXXXXX views and attitudes, especially on homosexuality and that of his family. So, it is important to understand that as XXXXXXX has probably grown up amidst conflicting environments and caught up between drastically different cultural beliefs regarding his homosexuality. Understanding these differences is important from both a diagnostic point of view (for example, in the American syctem of classification, homosexuality is not considered as a psychiatric disorder, whereas it may be considered as a taboo and an abnormality in certain other cultures), as well as from a treatment perspective.

- Dr. Jonas Sundarakumar
Consultant Psychiatrist
Above answer was peer-reviewed by
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