Psychiatric Assessment -- GW -- September 1992

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