Since the time of Kraepelin, a pervasive and unwarranted mistrust of others has
been considered a cardinal feature of paranoid personality disorder. Other features that have been described prominently in the literature are sensitivity to
criticism, aggressiveness, rigidity, hypervigilance, and an excessive need for autonomy. We present the case of a patient with most of these classic characteristics
that represent key components of the diagnostic criteria for paranoid personality
disorder in the DSM-5 (Table 1).
“Mr. J” is a 65-year-old Caucasian man with no prior psychiatric history, history of chronic obstructive pulmonary disease, and a benign vocal cord lesion.
He was brought to the emergency department by police for concerns of psychosis and delusions. Records stated that the “patient is delusional, in a state of acute psychosis, easily agitated.”
Upon initial contact with the emergency department psychiatrist, the patient reported feeling that the staff at the hospital were against him. He reported never having seen a psychiatrist before, although he reported having been on a selective serotonin reuptake inhibitor in the past to help equilibrate his “serotonin levels.” He did not fully cooperate with the interview, was guarded and evasive, and often said, “You don’t need
to know.” His mental status examination was notable for disorganized process and paranoid content. During the latter part of the assessment, the patient became loud, intrusive, and agitated.
He pounded his cane on the ground and threw it to the floor in a threatening manner.