Growing up, Mr. A shared his neighbors’ suspicion of white people. Further, his overvalued conspiracy theory involving his wife might have projected his own guilt over his infidelity onto a pre-existing paranoid personality.
Based on his psychosocial history, rapid progress in psychotherapy, and marked improvement in Outcome Questionnaire 45.2 scores, Mr. A does not have a personality disorder. What’s more, paranoid ideation is not uncommon in African-Americans with depressive symptoms, as demonstrated by Bazargan et al. 3
Mr. A’s diagnosis was changed to major depressive disorder, moderate, in partial remission. He is still seen approximately every 6 weeks for medication maintenance; he continues taking fluoxetine, 20 mg/d.
MR. B’S CASE: ‘Singled’ out
Mr. B, age 42 and African-American, was referred from an alcohol rehabilitation program to the psychiatry unit after exhibiting depressive and paranoid symptoms.
After 17 years with his employer, he started clashing with his supervisors and coworkers—most of whom are white. He claimed his colleagues were talking behind his back, jealous that he is single and spends his evenings at nightclubs. He alleged that his bosses were singling him out after he was transferred to another department and reprimanded for arriving late to work. Resultant worry about job security brought on panic symptoms (shortness of breath, lightheadedness, dissociative feelings, and palpitations).
Upon further questioning, Mr. B said he felt depressed and isolated. He had been prescribed nortriptyline 2 years ago but discontinued it after a few weeks because of side effects.
Mr. B said that not having a steady companion contributed to his depression and alcohol use. He had been drinking heavily for about 3 years, consuming at least a six-pack daily. He acknowledged that his suspicion of his white coworkers long preceded his alcoholism. Still, he did not see this mistrust as a problem.
Mr. B was diagnosed with major depressive disorder, severe with psychotic features. Treatment consisted of:
- paroxetine, 20 mg/d
- attendance at Alcoholics Anonymous meetings (at least three meetings per week were recommended)
- and 12 sessions of interpersonal psychotherapy. During these sessions, the therapist began to uncover the roots of Mr. B’s symptoms.
School days. Mr. B described how, as a little boy, he once watched his mother being beaten by his drunken father. He told the therapist that the beatings occurred frequently.
When he was age 5, Mr. B’s parents divorced and he and his mother moved to a mostly white Midwest neighborhood so that he could attend a high school with an advanced music program (he was honored for exceptional talent on several instruments).
In his youth, Mr. B’s mother repeatedly told him that teachers and students would treat him “differently” because of his color, though she never explained what she meant. While in high school, he began to worry about his social functioning, appearance, work performance, and future accomplishments.
After four psychotherapy sessions, Mr. B revealed that while in grade school, he was sexually assaulted by an older white boy. For more than 30 years, he had told no one. He denied hyperautonomic and re-experiencing symptoms but realized that this incident may have kept him from starting a romantic relationship.
After psychotherapy, Mr. B reported reduced depression and increased social interaction. His Beck Depression Inventory score dropped from 23 (moderate depression) to 4 (normal mood), and his Beck Anxiety Inventory score improved from 33 (moderate anxiety) to 3 (very low anxiety). He has been sober for 6 months and handles stress more effectively, although his mistrust toward coworkers is still apparent.
How would you diagnose Mr. B? Do his symptoms characterize “psychotic features” or an anxiety or alcohol-related disorder?
Dr. Benzick’s observations
Mr. B’s case illustrates how deep-seated cultural perceptions and past trauma together can cause severe anxiety—and how that anxiety can be misperceived as psychosis.4 Anxiety also can manifest as paranoia in “psychotically vulnerable” individuals.5-7
Chronic anxiety seemed to cause Mr. B’s depressed mood and social withdrawal. Several anxiety disorder diagnoses were considered, including:
- panic disorder
- posttraumatic stress disorder
- social phobia
- alcohol-induced anxiety disorder
- and generalized anxiety disorder.
Mr. B, however, exhibited no evidence of repeated episodic anxiety, nor did he describe reexperiencing phenomena. His anxiety extended beyond social situations and preceded his heavy alcohol consumption. Paranoid personality disorder was also considered, but Mr. B sought relationships and lacked the angry, unforgiving qualities associated with this pathology. Finally, a battery of psychological tests did not reveal frank psychosis but suggested an avoidant personality style.
Mr. B’s diagnosis was changed to generalized anxiety disorder. He requested a trial off medications during the latter stages of therapy, but his severe anxiety returned. He was then prescribed venlafaxine, 37.5 mg/d titrated to 225 mg/d across 3 weeks. His anxiety symptoms again abated.