1. The patient, a single female with numerous medical issues including diabetes and amputations, was referred for evaluation due to demanding behavior and hoarding medications at the nursing home. 2. Upon mental status exam, the patient was alert but irritable at times, and displayed marginal insight and judgment. 3. The evaluator believes the patient has a mild paranoid personality disorder based on her mistrust and suspicion of others, tendency towards anger and argumentation, and creation of a self-defeating cycle of expecting rejection and responding with hostility.

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Mental Health Consultation
Patient Name: hostile-dependent vicious-cycle Facility: XXX
Date: x-x-xx
For the sake of brevity and timeliness, the following sections will not be included in this
report: Background Information: Current Medications: Medical History: That
information can be found elsewhere in this chart.
Reasonfor Referral: xx-year-old, single, female… I was asked to evaluate her because she
has been “demanding, throwing dishes, hoarding medications”. Progress notes show that her
behavior, though at times demanding, is usually under control. When she was caught hiding
medications in her bed by nursing staff, she threw a full cup of water at the nurse. She was
admitted from XXXX on x-x-xx where she was treated for a left gluteal abscess. Among her
numerous other medical problems are: Type II Diabetes, CAD, COPD, HTN, PVD, Chronic
Pain Syndrome and Atrial fibrillation. She attends hemodialysis three times a week. Both of
her lower limbs have been amputated, one above the knee and one below the knee. Among
other medications she takes Coumadin, Lisinopril, digoxin, Clopidogrel and Tramadol for
pain but no psychotropic medications. She has one daughter from whom she is estranged.
She is cared for in her Xxxx apartment by xxxxxx. She was recently admitted; as a result,
her chart contains almost no useful history or clinical information.
Mental Status Exam: She was a very large lady lying in bed with a sheet wrapped around
her. She would not engage with me until I personally held her emesis basin while she spit
into it. Previously, I had asked a nursing staff member to bring her an emesis basin but after
using it she immediately worked up a new mouthful of saliva. This was clearly a test
involving control and her notion of respect. She was alert and fully oriented with a clear
sensorium. Her speech was spontaneous coherent and relevant. She said that the Nursing
Home was mostly “okay” but she was angry about two things: “they take hours to respond
to a call and some of the staff here are prejudice”. Her affect was full and her mood was at
times pleasant at other times irritable. She denied depression and biological signs of
depression such as early morning awakening, loss of appetite with weight loss, anedonia, low
energy and crying spells. There were no signs of psychosis or delirium. Her insight and
judgment were marginal.
Findings and Recommendations: Having only my clinical interview to be guided by, I
believe this lady has a mild personality disorder. Primarily a paranoid personality. These
individuals are mistrustful of others and suspicious of the motives and intentions of those
around them. They tend to be loners with few close, personal relationships. They can be
impressive and even charming, but are always looking for hidden meanings in the speech and
behavior of the people they encounter. They can be argumentative and quarrelsome and their
impatience is often expressed in angry, emotional outbursts. They sometimes convey an
attitude of superiority, arrogance and grandiosity which antagonizes other people.

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They can unconsciously create the following self-defeating paranoid vicious cycle: they
expect to be rejected; as a result, they are hostile to others and reject before they are rejected;
because of their defensiveness and hostility, others reject them; this confirms their original
belief that most people are hostile to them and the cycle is repeated over and over again with
each new interpersonal contact.
1. Psychiatric medication is of little befit in these cases.
2. Staff should avoid appearing directive with her. She would see this as a threat to her
self-esteem and become oppositional as a means of asserting her autonomy. Always
treat her with respect she is looking for slights and rejections. Always allow her a face
saving way out of a conflict or situation.
3. Do not allow her to make you feel responsible for immediately solving her problems.
Do not be intimidated by her. Do not try to win her approval. Do not allow her to
draw you into an argument or force you into defending yourself.
4. Remind her that she is ultimately responsible for her own health and health care.
Others can make recommendations but in the final analysis the choices and outcomes
are hers.
5. Do not allow her to lure you into agreeing with her criticisms of any other members
of the staff.
6. If she makes a provocative remark, try to be matter-of-fact in your response. Avoid
any statements which she could perceive judgmental or moralistic. Never show
irritation.
7. Model self-regulation by speaking and moving, calmly and slowly when dealing with
her.
8. When she makes unreasonable demands tell her you will help her with a task but you
will not do the job for her. Say that doing the job for her implies a lack of competence
on her part and you intend to treat her as a competent adult. If you try to meet her
dependency needs, she will respond with hostility and rejection. The more you do for
her the less competent she feels and the more she will resent you for generating those
feelings in her. Do not get caught in this hostile-dependent vicious-cycle; assist her
only with tasks she is incapable of completing on her own.
9. Break the vicious-cycles by neither rejecting her nor trying to win her approval.
___________________________ This document was created using voice recognition software.
Drew Chenelly, Psy.D.
Clinical Neuropsychologist