Question

A sixty-year-old man is seen by a social worker for evaluation of health care needs for himself and his bedridden wife. He is apparently healthy, with no evidence of impairment in thinking or memory. He has been caring for his wife, but has been reluctantly persuaded to seek help because her condition has deteriorated, and his strength and energy have decreased. A history is obtained from the subject and his daughter. He has never been treated for mental illness, and in fact has always claimed to be "immune to psychological problems" and to act only on the basis of "rational" thought. He had a moderately successful career as a lawyer and businessman. He had been married for 25 years, and his wife is the only person for whom he has ever expressed tender feelings, and is probably the only person he has ever trusted. He has always been extremely careful about revealing anything of himself to others, assuming that they are out to take something away from him. He refuses obviously sincere offers of help from acquaintances because he suspects their motives. He never reveals his identity to a caller without first questioning him as to the nature of his business. Throughout his life there have been numerous occasions on which he has displayed exaggerated suspiciousness, sometimes of almost delusional proportions (e.g., storing letters from a client in a secret safe deposit box so that he could use them as evidence in the event that the client attempted to sue him for mismanagement of an estate) He has always involved himself in "useful work" during his waking hours, and claims never to have time for play, even during the 2 years he has been retired. He spends many hours monitoring his stock market investments, and has changed brokers several times when he suspected that minor errors on monthly statements were evidence of the brokers' attempt to cover up fraudulent deals.

1.) A diagnosis using DSM-5 criteria

2.) A rationale for the diagnosis

3.) What could be a few other diagnoses

4.) Ways of treatment

Answer 1

Based on the interpretation of the case I'll answer your questions with reference to the criteria mentioned in DSM 5.

1.) The symptoms and the qualities that the man is exhibiting match with the diagnostic criteria for Paranoid Personality Disorder. The man is said to be suspicious and always doubting the motives of others. This is seen as a preoccupation because he doesn't seek help from literally anyone. The symptoms involve suspecting people without sufficient basis that people would harm or deceive them. They are preoccupied with doubts about loyalty of their known people. People suffering from paranoid personality disorder are also seen less to confide in others which also seems to be true in this man's case as he is said to express his feelings only to his wife. Also another important criteria is that all this doesn't happen along with the course of any other disorder. This is also to be noted as the man has no such history. He seems to fit into all these symptoms and hence this is one major diagnosis.

2.) The rationale for this diagnosis is largely based on the symptoms that the man exhibits. People suffering from this disorder find it difficult to get well along with others which is true in this man's case. He is not found to get well along with anyone except his wife. Such people are also very alert and vigilant about potential threats that can arise which is again seen in this man as he is found to store letters from clients in a secret box so that he could use it in case things went wrong. They also appear to be rationale as this man says he is. It is also seen that he has been reluctantly pursuaded to seek help because his wife's condition was deteriorating. This could be because this man doesn't trust anyone and might therefore have a need to be self-sufficient to be the sole caregiver for his wife, again a common feature of people suffering from this disorder.

3.) Another possible diagnosis could be Schizoid Personality Disorder. People who have this disorder usually have themselves restricted to express their emotions to only some close people. Here the man has expressed his tender feelings only to his wife which shows a possibility of this disorder as well. However in order to confirm this comorbidity we will need to know more about the relationships of this man with his family and close friends.

4.) The man can be treated with many possible treatment plans. One possible treatment could be use of Cognitive Behavioral Therapy (CBT). CBT can help to deal with the distorted patterns of thinking that this man has and may help him to modify his maladaptive behaviour of suspicion on others. Sometimes psychotherapy can also be helpful. This man can be given drugs like antidepressants and anti anxiety medication. Another possible treatment could be a combination of medication as well as psychotherapy.