The George Washington University Medical Center

Department of Psychiatry
2150 Pennsylvania Avenue, N.W.
Washington, D.C. 20037

September 24, 1992

PSYCHIATRIC ASSESSMENT
PATIENT: Gary Freedman
DATE OF ASSESSMENT: [9-8-92/9-15-92]
CLINICIAN NAME: Napoleon Cuenco, M.D., PGY-3

IDENTIFYING DATA: The patient is a 38-year-old single white male, a law

graduate, born and raised in Pennsylvania, who is currently unemployed. He
used to work as a legal assistant.

CHIEF COMPLAINT: Feelings of loneliness, isolation, and hopelessness of

several months' duration.

HISTORY OF PRESENT ILLNESS: Patient said that he has had various

contacts with mental health professionals since age 19. Reportedly, he was
doing relatively well until he was terminated from his job as a legal assistant
last October 1991. He said that he got fired in spite of excellent evaluations he
earned during his three years of stay in the office. In retrospect, he feels that
the evaluations were a mere cover-up to the negative thoughts people had
about him. All along he knew that there was a scheme against him and this was
probably due to his coworkers' concerns about his "weird personality." He said
that they thought that he was a homosexual and that he was crazy. He said that
they also believed that his office-mates were scared of him because they
thought that impulsively he could just get a gun and shoot everyone. Patient
said that he has had similar difficulties in the past, that he tends to elicit a
similar response from people. He feels that people tend to be paranoid about
him, to take advantage of him, and to trap him in double-bind situations. As a
result, he feels that he has become increasingly lonely. He feels isolated and
somewhat hopeless. He has not been in contact with anyone outside his family.
He spends his days ruminating about his difficulties. Patient denied feeling
suicidal or homicidal, however. He has not had any appetite changes. However,
energy level is increased. Occasionally, he has racing thoughts. Frequently, he
feels hyped up. Lately, he has been feeling very motivated. He has been writing
his thoughts up to the wee hours of the morning and feels less need for sleep.

MEDICAL HISTORY: Patient broke his arm in a car accident two years ago.
He was hospitalized for two days with no serious sequelae. He has no history of
seizures, head trauma or any major medical illnesses.

PSYCHIATRIC HISTORY: Patient has had various contacts with mental

health professionals since age 19. Several of these were one or two session
consultations. At age 23, following the death of his father, he reportedly
suffered from a severe depression. He was prescribed Elavil which he
discontinued because of the development of side-effects. A few months later,
he tried to kill himself by overdosing on the medication. Following the
hospitalization, he has been in off-and-on psychotherapy with various
psychiatrists, at least two of which lasted about one-and-one-half years. Patient
reportedly terminated whenever he felt that the therapists were in
communication with his employers or were no longer helpful to him. He was
also prescribed Ativan for a few years. Reportedly, the medication was helpful
to him. Patient reports that one of his former psychiatrists recommended a
trial of Lithium and neuroleptics [sic] because of concerns that he may be
manic depressive.

SUBSTANCE USE HISTORY: The patient denies having abused drugs in the
past. He has a questionable history of alcohol abuse. Reportedly, his family was
concerned that he may be alcoholic. He claims that he has not had any
problems with alcohol, however.

LEGAL HISTORY: Negative.

PERSONAL HISTORY: The patient was born and raised in Philadelphia,

Pennsylvania. He is the younger of two siblings. He was raised by his parents
and a maternal aunt. Reportedly, the interaction amongst his caretakers played
a crucial role in the formation of his "fragile character structure." Patient
reported that he was very dependent on his mother during his childhood. The
mother, on the other hand, was extremely dependent on her only sibling, the
maternal aunt, for strength and emotional support. Meanwhile, the father, for
the most part, relegated most of his powers defensively to the maternal aunt so
that within the family structure he was perceived by the patient to have been
more of a brother or an older friend than a father. The patient said that he had
better social skills as a child than as an adult.

Though a bit shy and withdrawn, he had a few friends. In fact, from age 9 to
age 14 or so, he had one best friend. He felt very attached to this male friend.
Reportedly they had a lot of fun and spent a lot of time together. Patient said,
however, that he felt that the closeness was perceived by his family in a
malicious sort of way. Reportedly, he heard his brother-in-law on several
occasions make snide remarks about the friendship and expressed concerns
about the homoerotic nature of the relationship. This bothered the patient
and made him panic. He then decided to withdraw from his friend and from
then on he has not had any sort of involvement outside a few superficial
intellectual encounters, mostly with men he admired in school and later at
work. Meanwhile, he diverted all his attention to his father whom he felt was
all accepting and supportive of him. He said that for a while following the
breakup of his friendship, he idealized his father to the exclusion of almost
everyone else.

After high school, the patient went on to college with no significant

difficulties. He then worked for a couple of years as a researcher before
proceeding to law school. It was around that time when the father died.
Following the tragedy, the patient had his first depressive episode. Reportedly,
on at least two occasions, the depression alternated with feelings of distressful
euphoria, increased motivation, decreased need for rest, and racing thoughts.
And since then, patient has been in off-and-on psychotherapy. Patient said that
while he was in law school, he had one serious heterosexual involvement.
Reportedly, the affair lasted two years. They eventually broke off, however,
because of patient's refusal to commit himself into marriage before graduation.
Patient claims that the breakup transpired over the phone and that it did not
cause him any significant distress. Following graduation from law school,
patient came to D.C. to do his Masters in International Law. Following this, he
reportedly had difficulty finding a job as a lawyer and had to settle for a legal
assistant position in spite of excellent scholastic records. He has always felt bad
about this. He feels that it puts him in a situation that invites a lot of envy and
power struggles. On one hand, he feels that people he works with at his level
feel insecure about his being a lawyer; on the other, he feels that the lawyers he
works for are threatened by him.

FAMILY HISTORY: The patient denies a family history of mental illness. His
father died in 1976 from complications of a coronary bypass operation. The
patient felt very close to him and loved him dearly. He said that this was in
spite of his perceptions that the father all along was defenseless against his wife
and his sister-in-law, and thus was powerless in the household. The mother
died in 1980 from a cerebrovascular accident. Reportedly, she had a strange
relationship with her husband. She was perceived as weak and ineffectual.
Moreover, under the influence of her sister, she appeared strong and in
control. The maternal aunt is a lady whose whereabouts are not known to the
patient. She was last seen during her sister's funeral. She is remembered as a
powerful manipulator of the family. Although she never lived with the patient's
family and had her own home, she reportedly ruled the family from afar. The
patient compares her to the set-up that exists between an abusive colonial
power and an enslaved territory. The patient has one sibling, a sister six years
his senior. She is married with two children. The patient feels very close to her.
The patient has mixed feelings about his brother-in-law.

MENTAL STATUS EXAMINATION: Patient came to both interviews

appropriately groomed and dressed. He appeared his stated age. He spoke with
a normal tone of voice. His speech was pressured and rapid but clear. He
manifested flight of ideas and occasional looseness of associations. He had
paranoid ideations which occasionally bordered on a delusional level. He was
not suicidal or homicidal. He denied ever having had any perceptual
disturbances. Patient appeared anxious more during the first interview than
the second. He was much more comfortable talking about his thoughts and
ideas than about his feelings. When confronted with questions associated with
his mood and affect, he withdrew and became defensive. He said he felt sad
isolated and somewhat hopeless. He, however, denied any problems with his
sleep or appetite. On both occasions, he had fast thoughts and felt very
motivated. His affect was intense though somewhat constricted. The patient
was oriented to time, place, person and situation. Short and long-term
memory were intact. Calculation, abstraction, fund of general information and
tested judgment were good. Intelligence seemed about average. Insight was
poor.

IMPRESSION: The patient is a 38-year-old white male who feels extremely

isolated and trapped. He is grappling with issues surrounding his sexual
identity and his fears of intimacy. He has unresolved grief about major losses
in his life, namely the loss of his best friend during adolescence, the death of
his father, the death of his mother and a step-down in his career. He uses
projection as a means of warding off forbidden thoughts and wishes which
center on his sexuality, low self-esteem, and interpersonal difficulties.

At present, patient seems to fulfill the criteria of a major affective disorder.

Although he does not fulfill the criteria of either a major depressive episode or
a full manic syndrome currently, he has a mixture of both and his symptoms
have been significantly affecting his functioning in a pervasive manner. In spite
of a clear history of a major depressive episode in the past, at best, he has only
had hypomanic symptoms previously and at present. The closest diagnosis is
probably a bipolar disorder NOS with mood congruent psychotic features.
However, the possibility of a schizoaffective disorder cannot be ruled out
entirely. The patient is open to the possibilty of being put on medications. A
trial of mood stabilizers and short-term neuroleptics seem in order. Meanwhile,
he should be given the chance to work through his psychosocial difficulties in a
psychotherapeutic process.
DIAGNOSIS:

Axis I - Bipolar disorder NOS

Rule out schizoaffective disorder
Axis II - Deferred
Axis III - None
Axis IV - Severe
Axis V - 50

TREATMENT RECOMMENDATIONS:

1. Psychopharmacologic treatment with a mood stabilizer like Lithium and

possible short-term use of neuroleptics.

2. Supportive psychotherapy aimed at addressing unresolved grief about

father's death, mother's death, sexual orientation, and interpersonal
difficulties.

[signed]

Napoleon Cuenco, M.D.

PGY-3

[not signed]

Daniel Tsao, M.D.

Attending Psychiatrist

NC/bet
George Washington University Medical Center
Department of Psychiatry and Behavioral Sciences
2150 Pennsylvania Ave., N.W.
Washington, DC 20037

LIMITED PSYCHOLOGICAL EVALUATION

NAME: Gary Freedman

DOB: 12-23-53
REFERRED BY: Dimitrios Georgopoulos, MD
DATE OF SERVICE 3-11-96

REFERRAL QUESTION:

Mr. Freedman was referred for assessment of formal thought disorder as a part of
differential diagnostic evaluation.

TESTS ADMINISTERED:

SCL-90-R
Wisconsin Card Sorting Test (WCST)
Whitaker inventory (WIST)

PRESENTING PROBLEM AND BACKGROUND INFORMATION:

Mr. Freedman is a 43 year old single white male with complaints of suspiciousness
about his ex-employers and depressive feelings. He was terminated from his job in
October 1991 after 3 years of employment and since then has been unemployed. His
former employers claimed that he was "too paranoid," hostile and potentially violent.
Mr. Freedman describes himself as being hypersensitive to peoples' non-verbal cues,
tone and inflections. He believes that he is under surveillance by his former employers
who do this to protect him and maintain continuity with his life. One of the methods of
surveillance, according to Mr. Freedman, is by entering his apartment when he is out.
He claims that his special ability to sense his environment validates his belief that
there are people who feel hostile towards him and persecute him. As a result, he has
isolated himself, and feels lonely and distressed because of this.

Mr. Freedman has been in individual treatment with Dr. Georgopoulos for about two
years. Although he reports emotional problems since young adulthood he has never
been hospitalized in a psychiatric unit.

A previous psychological evaluation on 5-11-94 reported an enduring pattern of

increased sensitivity, hypervigilance, and outright suspiciousness, expressed hostility
and self-protective withdrawal. Although no Axis I diagnosis was suggested in this
evaluation, Mr. Freedman confided in his therapist that he had denied certain
statements pertaining to his persecutory beliefs on the objective tests.

BEHAVIORAL OBSERVATION:

Mr. Freedman was cooperative throughout the session and worked on the tests
diligently with good concentration. His speech was somewhat pressured and loud. The
content of his speech was somewhat vague, however he did not show any obvious
indications of flight of ideas or incoherence. He talked about certain "beliefs" about his
ex-employer however his description of these beliefs was not clear. He expressed the
belief that his employers have a key to his apartment and have visited his apartment in
his absence. He was rather guarded when the examiner asked more questions about
these beliefs.

TEST RESULTS:

SCL-90-R is a 90 item self-report symptom inventory which measures psychological

distress in terms of 9 primary symptom dimensions and 3 global indices of distress. In
reference to outpatient norms Mr. Freedman reported very low general symptomatic
distress level and overall intensity of distress. Such SCL-90 pattern is often associated
with a repressive or defensive response style. However, Mr. Freedman indicated that
he is extremely distressed by having ideas or beliefs that others do not share.

The Wisconsin Card Sorting Test is a measure of concept learning and cognitive
flexibility. Deficient performance is often associated with dysfunction of frontal lobes.
Mr. Freedman performed within normal limits on this test. He completed all 6 category
sorts and made only 6 perseverative errors, both within the range of normal
functioning.

The Whitaker inventory is a measure of the formal thought disorder. Mr. Freedman
revealed no sign of loosening of associations, clanging or other evidence of cognitive
slippage on this test; his functioning was within normal range.

CONCLUSIONS AND RECOMMENDATIONS:

In the present limited assessment no signs of the formal thought disorder or frontal
lobe dysfunction were observed. Mr. Freedman presents a long history of
suspiciousness, lack of trust, reading threatening meanings in benign remarks or
events and isolative behavior. These characteristics are consistent with an Axis II
diagnosis of a personality disorder with prominent paranoid traits. However, this
diagnosis would not explain Mr. Freedman's delusional preoccupations with his former
employers. His description of these preoccupations are consistent with the description
of systematized and non-bizarre delusional beliefs. Presence of these delusions in the
absence of prominent mood symptoms, auditory hallucinations or formal thought
disorder is supportive of a diagnosis of delusional disorder. This diagnostic impression
is consistent with findings on MMPI and Rorschach from previous psychological
evaluation as well as absence of formal thought disorder in this evaluation.

In view of this diagnostic impression a trial on narcoleptic medications is indicated. The

benefits of medication and possible side effects need to be discussed with Mr.
Freedman in the context of an ongoing therapeutic relationship with his current
therapist.

[signed]

Ramin Mojtabai,
Psychology Intern