Hi XXXXXXX

When making a treatment plan, it would be useful for the clinicial / therapist to first make a problem chart to understand which areas need to be addressed. Though you may have made a specific diagnosis, remember, we have treat the "patient" who has come to you in distress with his problems, and not the "diagnosis".

In Danial's case, I would identify the following problem areas:

1) Personality problems - paranoid personality disorder

2) Drinking problems - alcohol abuse / ? dependence pattern

3) His mood instabilities / past episode of depression (with suicidal ideas)

4) Problems with his job and people at his workplace

5) Problems with his family - conflicts with his father, rivalry with his brother, and cultural problems regarding his homosexual orientation

6) Problems / potential problems with his partner (Danial has already started suspecting and mistrusting his partner)

In order to make a more objective assessment, I would employ the following psychological instruments to rate the severity of his problems:

1)     Brief Psychiatric Rating Scale (BPRS) – to rate the overall severity of his symptoms.
2)     The Paranoid Personality Disorder Features Questionnaire (PPDFQ):- The PPDFQ (Useda, 2002) is a dimensional measure that assesses the six main traits associated with Paranoid Personality Disorder (PPD) as described by the clinical and theoretical literature on PPD. PPDFQ provides additional diagnostic information (i.e., the presence and degree of impairment associated with specific maladaptive variants of the core personality traits of PPD.
3)     Alcohol Use Disorders Identification Test (AUDIT) – to identify the pattern, extent and severity of his alcohol use.

Now, since Danial seems to have multiple problems involving multiple spheres in his life, the treatment approach has to be multi-dimensional. Treatment should not only involve him but should also involve the 'significant others' involved in his life. A large majority of his problems seem to be stemming out of his paranoid personality - due to his mistrust, suspiciousness and difficulty in forming stable relationships with anyone. So, the predominant form of treatment would be psychotherapy.

First, the goal of therapy with PPD patients is to help them recognize and accept their own feelings of vulnerability; heighten their feelings of self-worth and reduce their feelings of shame; help them develop a more balanced, trusting view of others; and reduce their reliance on counterproductive self-protective strategies, such as threatening, and intimidating others and keeping others at a distance. A variety of therapeutic approaches could be employed to accomplish these goals (e.g., cognitive-behavioral therapy, psychodynamic psychotherapy). Supportive therapy is often useful as it can help alleviate the patient’s distress and help form a better rapport with the therapist.

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. So, therapy should have realistic aims of reducing the paranoia and limiting its impact on the person's daily functioning, rather than expecting a complete cure.

However, many individuals with PPD have some capacity to take perspective on their own suspicious cognitions. An approach of “collaborative empiricism” can be very helpful in this regard, in which the therapist invites the patient to join in a process of examining his or her beliefs in the light of objective evidence. Thought records can be used to help the patient identify and modify his or her maladaptive cognitions by weighing the evidence supporting them and contradicting them.

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.

In some cases, medication may be needed to control severe agitation or for thinking bordering on delusional beliefs. Anti-psychotics and mood stabilizers have been tried with limited success.

On a detailed exploration and subsequent sessions, if it becomes clear that Danial may be having a co-existing mood disorder, then appropriate medication may be required.

Danial may also need help for his alcohol problems, and treatment should be planned according to the severity of the problem. This is important because, alcohol itself could be worsening his paranoia and hence it is important to minimize the adverse impact of alcohol on his pre-existing problems.

It is also important to help Danial form some meaningful social relationships – atleast with one or two close relatives or friends, as this would help in better social integration and functioning. So, involving his family or partner in therapy will help this process.

Thus, a multi-dimensional approach, which addresses his multiple problems and focuses on improving his overall social-occupational functioning level, is essential.


- Dr. Jonas Sundarakumar
Consultant Psychiatrist

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