Thank you for the opportunity to reply to Dr. Hunasikatti’s comments regarding our article.1 He brings up some excellent points and we appreciate the opportunity to clarify.
With regards to our example of Cluster A personality, the elderly individual with paranoia, we agree that the differential must include delirium and dementia and an appropriate work-up completed. The intent of the vignette was to illustrate a functional but eccentric individual with paranoid beliefs. The paranoia associated with paranoid personality disorder is classically not responsive to medications—nor are patients typically amenable to such treatment—and behavioral interventions remain paramount, minimizing the negative impact of paranoia on the individual’s care.2,3
Regarding Ms. B, the vignette stated that the pain service was consulted, as Dr. Hunasikatti suggested it should be, but despite aggressive pain control, requests for opiates continued. We agree that appropriate pain management is critical in management of all patients, and pain can exacerbate behavioral issues when insufficiently treated. However, individuals who look to external sources of comfort may continue to request pain medications beyond what is clinically prudent and can benefit from learning additional skills to self-soothe and manage the psychological aspects of pain.4,5