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Have Major Depressive Disorder, Bipolar II Disorder And Depression And Paranoid Personality Disorder. Any Treatment?
Question: We had to do a reformulation of XXXXXXX case based on the new information below….
You have asked XXXXXXX to bring his wife to his second session. He arrives with his wife, XXXXXXX. You ask how he is doing today, and surprisingly he becomes quite agitated. He tells you it has been a terrible week because his second son "betrayed" him again. You learn that some years ago XXXXXXX disowned his eldest daughter after an argument. You try to get some detail about this, but XXXXXXX becomes too agitated to discuss the matter. The second son tried to mediate between XXXXXXX and his daughter last year. XXXXXXX responded that the son had to decide "which side he was on, just like in a war XXXXXXX and warned him never to raise this issue again. The eldest daughter recently gave birth to her first child, and wanted her parents to be involved in the child's life. She again asked the second son to mediate, and he attempted to do so.
XXXXXXX responded by accusing the son of being a traitor and throwing him out of the house. By the end of this account, XXXXXXX was tearful, exclaiming that there is nothing worse for a parent than when your own children betray you, plot against you, and stab you in the back. He notes that this is the price of greatness, to have those you love become jealous and turn on you. He speculates that this is because his second son "couldn't hack it" in the military and could not get into West Point as he, XXXXXXX had done. XXXXXXX felt that his son has harbored a grudge against him, and has been "just sharpening his knives for years, waiting for the right opportunity to cut me down XXXXXXX At this point, XXXXXXX stands up and says he needs to take a walk around the block to regain his composure, as it is unseemly for a war hero of his stature to lose control. He turns to XXXXXXX and says, "You tell the psychologist how these bastards have ripped my heart out XXXXXXX Wisely, you obtained a release of information and informed consent at the beginning of this interview, allowing you to obtain collateral information from XXXXXXX.
XXXXXXX is initially reluctant, but sheepishly begins to divulge some details. The original argument with the daughter occurred over a job XXXXXXX had lost. After losing a number of jobs because of his "bossiness XXXXXXX the daughter persuaded her father-in-law to hire XXXXXXX in his small business. Within weeks, XXXXXXX had the place in an uproar, and left in the middle of an important customer transaction, claiming it was immoral for him to work at a place that did not "support God and country XXXXXXX The daughter tried to explain to XXXXXXX the bind this placed her in. He called her a "Jezebel" and banished her from the family home.
In addition, since his discharge from the Army, XXXXXXX has held at least five or six other jobs in which he seemed to do well until he was ultimately fired for reasons that are not entirely clear. From what XXXXXXX has told XXXXXXX, it appears that the terminations were due to personality conflicts or nepotism by the owner of the business. XXXXXXX has been unemployed for the last three years, and is, XXXXXXX reports, frightened about applying for another job because of the possibility of rejection or failure (being fired again).
You also learn that XXXXXXX never actually attended West Point, but once attended training there while he was in the military. It was scheduled to last a month, but XXXXXXX was reassigned after a week. He refused to discuss why. XXXXXXX was never actually in combat. He was involved in ordnance supply but always says he was "close enough to the action to smell it XXXXXXX XXXXXXX begins to open up, and admits that XXXXXXX is hard to live with, but after so many years, there is "not much else to do XXXXXXX She also feels sorry for him, because he has no one else left in the world.
Previous:
Axis I: 296.23 Major Depressive Disorder, Single Episode, Severe Without Psychotic Features
Axis II: 301.82 Avoidant Personality Disorder
Axis III: None to Report
AXIS IV: Social, employment, and family
Axis V: 25
Reformulation:
Axis I: 296.23 Major Depressive Disorder, Single Episode, Severe Without Psychotic Features: 296.89 Bipolar II Disorder, Depressed, Moderate
Axis II: 301.0 Paranoid Personality Disorder
Axis III: None to Report
AXIS IV: Social, employment, and family
Axis V: 25
1. Describe your decision-making process in arriving at this reformulation.
In this new information for XXXXXXX this presents a strong diagnostic implications for Paranoid Personality Disorder as evidenced by suspicion without sufficient basis that others are exploiting or deceiving him (i.e. son being a traitor, , preoccupation with unjustified doubts about loyalty or trustworthiness (i.e. son has been “sharpening his knives for years, waiting for the right opportunity to cut me down”, banishing daughter from home due to being a “Jezebel”, companies “not supporting god and country”), reluctant to confide in others (i.e. contact with siblings is minimal and superficial due to fears of rejection in part 1, unrealistic importance on the support available from nuclear family in part 1), persistently bears grudges (i.e. superior military officer from part 1, children not being as devoted to him in part 1, daughter, son for not getting into West Point, father dying in part 1, mother’s attitude towards him from part 1), an onset at early adulthood, the pattern is inflexible, has clinically significant distress, and the pattern of cognitions (paranoid beliefs, grandiosity), affect (high irritability shifting to tearfulness), and impulse control (suicidal ideation, bossiness at work, leaving in the middle of an important customer transaction) is significantly deviant from the client’s culture. I would keep the diagnosis of Major Depressive Disorder, Single Episode due to his depressive symptoms are still a point of concern that I’m unwilling to ignore from part 1 even with continued information from part 2. I chose to lower the GAF score due to more information given in part 2, specifically the inability to function in almost areas (occupation, family, and friends) and serious impairment in judgment (grandiosity and paranoid beliefs). What are your thoughts?
2. What would be the presentations of non-DSM resources that describe how Axis II individuals often present.
Personality descriptions are looking at displays of normal personality and how one makes decisions. Personality evaluation is an outsider’s view on an individual’s way of making decisions. Your thoughts?
3. Evaluate the difficulties in accurately diagnosing personality disorders.
Taken into account that many personality disorders have some diagnostic criteria of grandiosity, a lack of honesty, or little trust in the people they interact with, this naïve trust is justified. Therefore, there are other instruments, interview structures, and tests that need to be taken into consideration before making a diagnosis of a personality disorder.
You have asked XXXXXXX to bring his wife to his second session. He arrives with his wife, XXXXXXX. You ask how he is doing today, and surprisingly he becomes quite agitated. He tells you it has been a terrible week because his second son "betrayed" him again. You learn that some years ago XXXXXXX disowned his eldest daughter after an argument. You try to get some detail about this, but XXXXXXX becomes too agitated to discuss the matter. The second son tried to mediate between XXXXXXX and his daughter last year. XXXXXXX responded that the son had to decide "which side he was on, just like in a war XXXXXXX and warned him never to raise this issue again. The eldest daughter recently gave birth to her first child, and wanted her parents to be involved in the child's life. She again asked the second son to mediate, and he attempted to do so.
XXXXXXX responded by accusing the son of being a traitor and throwing him out of the house. By the end of this account, XXXXXXX was tearful, exclaiming that there is nothing worse for a parent than when your own children betray you, plot against you, and stab you in the back. He notes that this is the price of greatness, to have those you love become jealous and turn on you. He speculates that this is because his second son "couldn't hack it" in the military and could not get into West Point as he, XXXXXXX had done. XXXXXXX felt that his son has harbored a grudge against him, and has been "just sharpening his knives for years, waiting for the right opportunity to cut me down XXXXXXX At this point, XXXXXXX stands up and says he needs to take a walk around the block to regain his composure, as it is unseemly for a war hero of his stature to lose control. He turns to XXXXXXX and says, "You tell the psychologist how these bastards have ripped my heart out XXXXXXX Wisely, you obtained a release of information and informed consent at the beginning of this interview, allowing you to obtain collateral information from XXXXXXX.
XXXXXXX is initially reluctant, but sheepishly begins to divulge some details. The original argument with the daughter occurred over a job XXXXXXX had lost. After losing a number of jobs because of his "bossiness XXXXXXX the daughter persuaded her father-in-law to hire XXXXXXX in his small business. Within weeks, XXXXXXX had the place in an uproar, and left in the middle of an important customer transaction, claiming it was immoral for him to work at a place that did not "support God and country XXXXXXX The daughter tried to explain to XXXXXXX the bind this placed her in. He called her a "Jezebel" and banished her from the family home.
In addition, since his discharge from the Army, XXXXXXX has held at least five or six other jobs in which he seemed to do well until he was ultimately fired for reasons that are not entirely clear. From what XXXXXXX has told XXXXXXX, it appears that the terminations were due to personality conflicts or nepotism by the owner of the business. XXXXXXX has been unemployed for the last three years, and is, XXXXXXX reports, frightened about applying for another job because of the possibility of rejection or failure (being fired again).
You also learn that XXXXXXX never actually attended West Point, but once attended training there while he was in the military. It was scheduled to last a month, but XXXXXXX was reassigned after a week. He refused to discuss why. XXXXXXX was never actually in combat. He was involved in ordnance supply but always says he was "close enough to the action to smell it XXXXXXX XXXXXXX begins to open up, and admits that XXXXXXX is hard to live with, but after so many years, there is "not much else to do XXXXXXX She also feels sorry for him, because he has no one else left in the world.
Previous:
Axis I: 296.23 Major Depressive Disorder, Single Episode, Severe Without Psychotic Features
Axis II: 301.82 Avoidant Personality Disorder
Axis III: None to Report
AXIS IV: Social, employment, and family
Axis V: 25
Reformulation:
Axis I: 296.23 Major Depressive Disorder, Single Episode, Severe Without Psychotic Features: 296.89 Bipolar II Disorder, Depressed, Moderate
Axis II: 301.0 Paranoid Personality Disorder
Axis III: None to Report
AXIS IV: Social, employment, and family
Axis V: 25
1. Describe your decision-making process in arriving at this reformulation.
In this new information for XXXXXXX this presents a strong diagnostic implications for Paranoid Personality Disorder as evidenced by suspicion without sufficient basis that others are exploiting or deceiving him (i.e. son being a traitor, , preoccupation with unjustified doubts about loyalty or trustworthiness (i.e. son has been “sharpening his knives for years, waiting for the right opportunity to cut me down”, banishing daughter from home due to being a “Jezebel”, companies “not supporting god and country”), reluctant to confide in others (i.e. contact with siblings is minimal and superficial due to fears of rejection in part 1, unrealistic importance on the support available from nuclear family in part 1), persistently bears grudges (i.e. superior military officer from part 1, children not being as devoted to him in part 1, daughter, son for not getting into West Point, father dying in part 1, mother’s attitude towards him from part 1), an onset at early adulthood, the pattern is inflexible, has clinically significant distress, and the pattern of cognitions (paranoid beliefs, grandiosity), affect (high irritability shifting to tearfulness), and impulse control (suicidal ideation, bossiness at work, leaving in the middle of an important customer transaction) is significantly deviant from the client’s culture. I would keep the diagnosis of Major Depressive Disorder, Single Episode due to his depressive symptoms are still a point of concern that I’m unwilling to ignore from part 1 even with continued information from part 2. I chose to lower the GAF score due to more information given in part 2, specifically the inability to function in almost areas (occupation, family, and friends) and serious impairment in judgment (grandiosity and paranoid beliefs). What are your thoughts?
2. What would be the presentations of non-DSM resources that describe how Axis II individuals often present.
Personality descriptions are looking at displays of normal personality and how one makes decisions. Personality evaluation is an outsider’s view on an individual’s way of making decisions. Your thoughts?
3. Evaluate the difficulties in accurately diagnosing personality disorders.
Taken into account that many personality disorders have some diagnostic criteria of grandiosity, a lack of honesty, or little trust in the people they interact with, this naïve trust is justified. Therefore, there are other instruments, interview structures, and tests that need to be taken into consideration before making a diagnosis of a personality disorder.
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Hi XXXXXXX
Thanks for your query.
With the new information, it comes to light that XXXXXXX has been having chronic, long-standing problems which seem to be stemming from his enduring maladaptive cognitive and behavioural patterns - which is not only causing significant distress to him and others around him, but also resulting in significant socio-occupational dysfunction. So, there is no doubt that he can be given an Axis II diagnosis of a personality disorder. As you have very nicely summarized the evidence, a Paranoid personality disorder would be the most obvious subtype here. So, your Axis II diagnosis is bang on target.
Just for argument's sake, it would be interesting to note that XXXXXXX also seems to have a few narcissistic personality traits as well...
- imagining unrealistic fantasies of success, intelligence, power ("thinks of himself as a war hero", training at West Point, grandiose ideas, etc.)
- requiring constant attention and positive reinforcement from others
- reacting to criticism with anger, shame, or humiliation
Of course, his paranoid personality traits are the most obvious, prominent and no doubt sufficient to qualify for a paranoid personality disorder, but for the sake of clinical arguement, you can mention the possibilty that XXXXXXX could be having a multiple personality disorder also (considering his paranoid, few narcissistic and avoidant traits)
Regarding the Axis I, I would agree with you that he would still qualify for a major depressive disorder because of the recent onset of full syndromal depressive symptoms. However I'm not sure about your differential of a Bipolar II part. I guess that you have taken into consideration the long-standing depressive symptoms interspersed with the grandiose ideas, inflated self-esteem, etc. But these qualities seem to be more pervasive and part of his personality rather than qualifying as a hypomanic episode. Remember, the crux of establishing a Bipolar diagnosis is "episodicity" (which means there should be episodes which stand out and there should have been intervals where he returns to complete normal functioning). In XXXXXXX case we are not able to establish this episodic pattern definitively.
Another small correction is that for the current depressive episode, you have given two different severity subtypes in your differential diagnosis, which is self-contradictory. Major Depressive Disorder, Single Episode, "Severe" Without Psychotic Features: 296.89 Bipolar II Disorder, Depressed, "Moderate" (both refer to the same episode and can't given two different severity subtypes)
Question 2: I agree with your views. Many people feel that being given a diagnosis of personality disorder is insulting and invalidating. A label of PD can be seen as critical of the individual rather than being a useful description of their experience and behaviour.
Some researchers have proposed that instead of labelling a person's difficulties in adapting with his family, culture or society as a disorder, the focus should be on "interpersonal relationship difficulties", which is a fundamental component of the unhealthy psychological functioning seen in people with personality problems. This focus would help clinicians in planning appropriate clinical interventions to help the patient rather than give him / her a 'hopeless' diagnosis.
People given a diagnosis of personality disorder have also had very difficult experiences in health services where stigma and discrimination have been pretty common, with devastating effect. For many years, it was thought that people given this diagnosis were untreatable. Difficult assumptions were made by service providers about the behaviour of people with a PD diagnosis, e.g. that they are manipulative, difficult or attention seeking. As a result, people given this diagnosis have often been unpopular within mental health services. They may have been turned away from services or not received the support and understanding that anyone in distress deserves.
Many clinicians and researchers believe that personality disorders are best understood from a continuous or dimensional perspective (or more like a dimmer switch). The benefit of this dimensional approach can be illustrated by contrasting people who have a Narcissistic Personality Disorder with people who do not. The Narcissistic Personality Disorder is characterized by rather extreme forms of self-centeredness and grandiosity; but even ordinary, healthy people will sometimes act in ways that are self-centered and grandiose. Though the dimension of self-centeredness is the same, the difference is in the extremity of expression. People with Narcissistic Personality Disorder behave in a self-centered manner most all the time, while people without this disorder behave this way only some of the time. In this case, it makes sense to talk about a continuum or dimension of self-centeredness, which varies from low to high.
Question 3: Difficulties in diagnosing personality disorders:
- Largely dependent on subjective views and judgements. So inter-rater reliability and stability of this diagnosis is poor.
- Socio-cultural variations make it difficult to clearly determine what is and what is not considered as deviant behaviour.
- Many personality disorders have overlapping symptoms or diagnostic criteria e.g. "inability to maintain healthy relationships", "manipulative behaviour", etc.
- Often there is an overlap between personality disorders and Axis I disorders. One good example of this is Schizotypal personality disorder (in DSM), which, in the latest version of the ICD has been re-classified as a separate Axis I diagnosis, along with Schizophrenia.
Regards,
Dr. Jonas Sundarakumar
Consultant Psychiatrist
Thanks for your query.
With the new information, it comes to light that XXXXXXX has been having chronic, long-standing problems which seem to be stemming from his enduring maladaptive cognitive and behavioural patterns - which is not only causing significant distress to him and others around him, but also resulting in significant socio-occupational dysfunction. So, there is no doubt that he can be given an Axis II diagnosis of a personality disorder. As you have very nicely summarized the evidence, a Paranoid personality disorder would be the most obvious subtype here. So, your Axis II diagnosis is bang on target.
Just for argument's sake, it would be interesting to note that XXXXXXX also seems to have a few narcissistic personality traits as well...
- imagining unrealistic fantasies of success, intelligence, power ("thinks of himself as a war hero", training at West Point, grandiose ideas, etc.)
- requiring constant attention and positive reinforcement from others
- reacting to criticism with anger, shame, or humiliation
Of course, his paranoid personality traits are the most obvious, prominent and no doubt sufficient to qualify for a paranoid personality disorder, but for the sake of clinical arguement, you can mention the possibilty that XXXXXXX could be having a multiple personality disorder also (considering his paranoid, few narcissistic and avoidant traits)
Regarding the Axis I, I would agree with you that he would still qualify for a major depressive disorder because of the recent onset of full syndromal depressive symptoms. However I'm not sure about your differential of a Bipolar II part. I guess that you have taken into consideration the long-standing depressive symptoms interspersed with the grandiose ideas, inflated self-esteem, etc. But these qualities seem to be more pervasive and part of his personality rather than qualifying as a hypomanic episode. Remember, the crux of establishing a Bipolar diagnosis is "episodicity" (which means there should be episodes which stand out and there should have been intervals where he returns to complete normal functioning). In XXXXXXX case we are not able to establish this episodic pattern definitively.
Another small correction is that for the current depressive episode, you have given two different severity subtypes in your differential diagnosis, which is self-contradictory. Major Depressive Disorder, Single Episode, "Severe" Without Psychotic Features: 296.89 Bipolar II Disorder, Depressed, "Moderate" (both refer to the same episode and can't given two different severity subtypes)
Question 2: I agree with your views. Many people feel that being given a diagnosis of personality disorder is insulting and invalidating. A label of PD can be seen as critical of the individual rather than being a useful description of their experience and behaviour.
Some researchers have proposed that instead of labelling a person's difficulties in adapting with his family, culture or society as a disorder, the focus should be on "interpersonal relationship difficulties", which is a fundamental component of the unhealthy psychological functioning seen in people with personality problems. This focus would help clinicians in planning appropriate clinical interventions to help the patient rather than give him / her a 'hopeless' diagnosis.
People given a diagnosis of personality disorder have also had very difficult experiences in health services where stigma and discrimination have been pretty common, with devastating effect. For many years, it was thought that people given this diagnosis were untreatable. Difficult assumptions were made by service providers about the behaviour of people with a PD diagnosis, e.g. that they are manipulative, difficult or attention seeking. As a result, people given this diagnosis have often been unpopular within mental health services. They may have been turned away from services or not received the support and understanding that anyone in distress deserves.
Many clinicians and researchers believe that personality disorders are best understood from a continuous or dimensional perspective (or more like a dimmer switch). The benefit of this dimensional approach can be illustrated by contrasting people who have a Narcissistic Personality Disorder with people who do not. The Narcissistic Personality Disorder is characterized by rather extreme forms of self-centeredness and grandiosity; but even ordinary, healthy people will sometimes act in ways that are self-centered and grandiose. Though the dimension of self-centeredness is the same, the difference is in the extremity of expression. People with Narcissistic Personality Disorder behave in a self-centered manner most all the time, while people without this disorder behave this way only some of the time. In this case, it makes sense to talk about a continuum or dimension of self-centeredness, which varies from low to high.
Question 3: Difficulties in diagnosing personality disorders:
- Largely dependent on subjective views and judgements. So inter-rater reliability and stability of this diagnosis is poor.
- Socio-cultural variations make it difficult to clearly determine what is and what is not considered as deviant behaviour.
- Many personality disorders have overlapping symptoms or diagnostic criteria e.g. "inability to maintain healthy relationships", "manipulative behaviour", etc.
- Often there is an overlap between personality disorders and Axis I disorders. One good example of this is Schizotypal personality disorder (in DSM), which, in the latest version of the ICD has been re-classified as a separate Axis I diagnosis, along with Schizophrenia.
Regards,
Dr. Jonas Sundarakumar
Consultant Psychiatrist
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Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
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