The George Washington University Medical Center
Department of Psychiatry and Behavioral Sciences
NAME: Gary Freedman
DOB: 10-27-64 [sic]
EDUCATION: Law Degree
DATES EXAMINED: May 4, 5, & 11 
REFERRED BY: Suzanne Pitts, M.D.
[Evaluator: Yu-Ling Han]
Mr. Freedman was referred for psychological evaluation to better determine a differential diagnosis. He reports having "personality difficulties in such a way that is nothing like what I've seen in others." His "unique personality" has caused chronic interpersonal difficulties most of his adult life. While Dr. Pitts would like to have a better understanding of which Axis I and which Axis II diagnoses contribute to his chronic interpersonal difficulties, Mr. Freedman would like to have a more "objective measure to understand my personality and to determine whether or not I am paranoid." [I was not on any medication at the time of testing, which is confirmed by the final paragraph of this report.]
Bender Visual Motor Gestalt Test
Millon Clinical Multiaxial Personality Inventory -- II
Minnesota Multiphasic Personality Inventory -- 1 (MMPI-1)
Rorschach Test -- Exner Scoring System
Thematic Apperception Test (TAT)
Wechsler Adult Intelligence Scale-Revised (WAIS-R)
The Worst Possible Concept Drawing
Mr. Freedman is a 40-year-old single, white male who has a law degree and an M.A. in International Law. Reportedly, although he had received excellent evaluations, after three years' employment with this law firm he was terminated in October 1991 because his employers claimed "I was too paranoid, hostile, and (they) feared the potential that I would become violent or homicidal." He has not worked since that time and spends his solitary time doing research and prolifically recording his thoughts in an autobiographical document. He continues feeling angry at, and preoccupied by, the way he was terminated.
He describes himself as being hypersensitive to peoples' non-verbal cues, tone and inflections. He believes that he is under surveillance by his former employer and that others are hostile towards him because they covet his intellectual abilities (On the other hand, he feels that his former employer’s motivation for putting him under surveillance is not malicious; rather, "it is their way of protecting me and maintaining continuity with my life.") He states that although both his former employer and various psychiatrists have described him as "paranoid and delusional," his special ability to sense his environment validates his belief that there are people who feel hostile towards and threatened by him, and who therefore persecute him. He dismisses people's alternative explanations of his experiences as "so feeble, that I am left to believe my own hypothesis." Although he distrusts most people, he feels lonely and distressed over the resulting isolation.
Mr. Freedman comes from a lower-middle-class background and grew up in Pennsylvania. He and his older sister were raised by his parents and maternal aunt. Retrospectively, as this aunt was a domineering person who easily influenced his more dependent mother, the "destructive interactions" amongst his three primary caretakers played a crucial role in the development of his "fragile character structure." He feels that because his parents defensively allowed this aunt to act as a powerful manipulator and relegated control over family affairs to her, he was left with an extreme sense of confusion over how to view his parents and ambivalent feelings towards them. He believes that he ended up having a "double Oedipus Complex" toward the two women in his life As he had minimal feelings of attachment, positive regard or respect towards his mother, he "had no emotional response to her death" when he was 26 years old. On the other hand, he was very attached to his father. Although Mr. Freedman felt that his father defensively gave up his role as the man in the house, his image of his father was that of an older brother or friend. Thus, he felt his father's death as a tremendous loss. In fact, he experienced his first major depressive episode following his father's death and tried to kill himself by overdosing on the antidepressant medication. Since that time Mr. Freedman has been in-and-out of psychotherapy. He has never been hospitalized for psychiatric-related difficulties.
He reports that he was very close to his sister while growing up. Currently, he has more mixed feelings about her. He talks about her in a somewhat disparaging way and believes that she is involved in the conspiracy to keep him under surveillance by providing his former employer with information about him.
Although he always had a few friends, he reports being more sociable as a child. He felt particularly close to a male friend. However, at age 14 he abruptly ended this five-year friendship because reportedly he heard his brother-in-law made comments about the homoerotic nature of this friendship. Since then, he has not involved himself in any type of gratifying friendships outside of intellectual and superficial encounters. He was involved in one serious heterosexual relationship back in 1988 [sic]. The relationship ended after two years as Mr. Freedman felt pressured to commit himself to marriage.
Mr. Freedman is a 40-year-old, white male who looks his stated age. He comes to the sessions casually but neatly dressed. He was oriented in all spheres. Both short- and long-term memory were intact. Although his speech was pressured and rapid, his use of language was articulate, expressive, and sophisticated. He did manifest circumstantial thinking and looseness of associations. Although not at a psychotic level, he exhibited marked paranoid ideation accompanied by delusional thinking. His thought content was notable for feelings of anger, entitlement and grandiosity on the one hand, and loneliness, depression and a craving for connection on the other. He expresses his feelings and conflicts using psychological metaphors and theoretical frameworks, although he has very limited insight into his difficulties. His affect was intense, though somewhat constricted.
All in all, his demeanor, response to the interpersonal nature of the testing situation, and approach to the tasks of the tests themselves were quite unique. For example, he immediately began the first session by giving me two voluminous, typewritten documents with the explanation that "These are my autobiographical documents. It is a systematic account of my thought processes that I have written down since I was fired from my job. You can get a better sense of my personality by reading this." Given this introduction, I had expected that he would be reticent in answering open-ended questions. However, he was both enthusiastic and very self-disclosive, although anxious and guarded about the testing situation.
He exhibited his apprehension about his performance on the tests in several ways. First, he felt a need to defend the integrity of his answers. He constantly sought to justify and explain his answers through elaborate rationalizations. On one occasion he brought in some researched information to validate the answer he had given in a testing session the week before. Second, he also tried to do research on the various tests he would be taking prior to their administration, in order to find out how to respond "so that I would come out looking normal." For example, he had some vague understanding of those scales on the MMPI which assess the validity of a person's response and psychological profile. In fact, Mr. Freedman reports that he had taken the MMPI a number of years ago and although "the Lie Scale indicated my responses were valid," his therapist went over each statement and challenged him to see whether his oral response matched his earlier paper-and-pencil response. Mr. Freedman's pressing desire to take the MMPI seems to be a token act to redeem himself from this memory of a person who seemingly injured and ruptured the relationship and Mr. Freedman's sense of integrity. For the Rorschach, he stated that, based on an article he had read in some psychological journal, he understands that integrating the whole blot and giving as many responses as possible per card is desirable. I tried to persuade him to answer as he normally would and that his assumptions based on the articles were indeed misleading. Third, during the Rorschach, he would stray away from the task by expressing his free-associated feelings of anger towards me whenever he felt frustrated in his attempts to maintain what he conceived of as his stellar performance.
Overall, his continual defensive and impression-management stance notwithstanding, he was cooperative throughout the testing session. He worked rapidly and with assurance when performing on the WAIS-R timed tasks; he tended to be elaborate with organizational details on tasks where no time limits were imposed. Given his superior verbal ability and extensive knowledge-base on disparate topics, he would tend to respond in an intentionally overly elaborate way in order to show off his verbal sophistication and complex thought processes.
Mr. Freedman is currently functioning at a superior level f intelligence according to his Full Scale IQ of 125 (95th percentile) on the WAIS-R. His Verbal IQ is 136 (99th percentile) and his performance IQ is 100 (50th percentile). The highly significant 36-point difference between his Verbal and Performance IQ was primarily associated with his very superior scores on two Verbal Scale sub-tests and his somewhat lower score on one Performance Scale subtest. Thus, while visuo-motor skills are more uniformly developed in the average range of functioning, verbal skills show more variability, with some abilities more superiorly developed than others.
A closer inspection of the notable differences in his sub-test results may be helpful in understanding his strengths as well as the difficulties that he does report. Within the verbal area, his learned memory ability, richness in ideas, and fund of information are excellent. Within the performance area, he has difficulty anticipating, judging, and interpreting both the antecedents and consequences of social situations would result in misguided assumptions. Furthermore, his proclivity to overintellectualize at times jeopardizes his ability to think clearly in situations calling for the application of social mores and expression of emotional relatedness. There is a tendency for him to challenge or denounce social sanctions, to a point where he may at times lose sight of his own best interests.
Mr. Freedman was asked to do two drawings. His initial response to the task of drawing a person was unique insofar as he chose to draw an elaborate impression of me. This may be seen as an attempt to distance himself from a task that has the potential of revealing himself and/or an attempt at flattering or being personal with me. His next drawing of a male figure suggests a person who is uneasy about his body and self-image. There is also indication of underlying but intense feelings of anxiety and aggression in his figure drawing. His Worst Possible Concept drawing which he entitled as "The Destruction of Optimism" is of an enormous and ominous sun setting the world ablaze and destroying it. This drawing is indicative of a person who feels lost and burdened. There is an evocative quality to his drawing which suggests that he may indeed be at the brink of despair and is fighting off feelings of destructive aggression.
Both his results on the MMPI-1 (Welsh Code of 564-82/093:7#1 FR/K:L#) and Millon instruments, which asses the severity of psychiatric symptoms, indicate no distinctive syndromes falling in the clinical range of Axis I psychiatric disorder. However, he is experiencing psychological dysfunction of mild to moderate severity that appear to reflect a pervasive pattern of personality difficulties. Both tests show elevations in the paranoid/avoidant scales, showing an enduring pattern of increased sensitivity, outright suspiciousness, expressed hostility, and self-protective withdrawal from interpersonal relationships. Although both test results reflect a valid profile, care must be taken in interpreting the results, as Mr. Freedman had reported to Dr. Pitts about his tendency to deny certain statements pertaining to his persecutory beliefs on these tests. Thus, the salience of the severity of his symptoms may need to be modulated slightly upward.
His Rorschach protocol is consistent with the above findings. The results are notable for hypervigilence aw it related to his interpersonal relatedness, depression as it relates to his overly-grandiose yet fragile self-image, and a disturbed and ideational thinking style. These personality features are deeply ingrained, causing him serious and chronic interpersonal difficulties.
There is mush cause for concern in the area of his interpersonal relations. A positive hypervigilant index suggests that he expends considerable energy in maintaining a relatively continuous state of preparedness. His relationships are characterized by superficiality, caution, and guardedness. Because of his great discomfort around emotions, he defends against his vulnerability by becoming socially constrained and isolated. Although he tends to be conservative in his interpersonal relationships, this does not mean that he has no desire for closeness. In fact, his central conflicts are (a) between his need to withdraw from people as a self-protection and his desire for a more gratifying relationship, and (between his efforts to become autonomous and independent and his dependency need for others to secure his sense of self-worth and appreciation. Furthermore, because of a long history of feeling injured ridiculed and betrayed by others, he has learned to anticipate pain, disillusionment, and humiliation.
Such deep conflicts, in tandem with failed attempts at asserting his integrity, stir deep resentments. Several of his TAT responses suggest feelings of deep resentment and contempt toward others, especially women. He often acts out his resentment in a petulant, forceful or aggressive manner. Such frequent outbursts jeopardize his need to feel affirmed. His displays of discontentment bind him to further isolation and feelings of humiliation. He copes through the use of fantasy, hopeless resignation, and the devaluation of others.
His depression is due primarily to difficulties in regulating his self-esteem. He has a great need to view himself in an overly grandiose way. He is so preoccupied and involved in sustaining his inflated sense of self that it dominates his perception of his environment. Thus he tends to filter information in an overtly personalized way. Unfortunately, his frequent need for reaffirmation and his failure to achieve it makes him vulnerable to repeated bouts of depression and anxious wariness towards others. He feels trapped in his conflict, for the very avenue for potential gratification is obstructed by the manner in which he has earned to compensate for the non-gratification of his needs. Risk for suicide must be monitored as he may act impulsively in his attempts to seek a dramatic form of retribution or solace from the bind he feels he is perpetually in.
Although he is quire uncomfortable in dealing with negative feelings, there are indications that he has the capacity to control and tolerate stress. He has an abundance of available resources which he uses through denial or externalization of his negative feelings; intellectualization is his primary defensive tactic. Thus, he is not experiencing much subjective distress. Consonant with this is his tendency to keep his emotions at a peripheral level during decision making. However, there are times when he may not be as stringent as other adults in modulating his affect and may discharge his emotions in a more obvious and intense way.
Although he is not experiencing much subjective distress, this does not mean his coping style is efficient. He is vulnerable to disorganization in complex and ambiguous situations. Furthermore, his Rorschach protocol does reveal that perceptual inaccuracy and mediational distortion occur as a result of a pervasive negative orientation toward his environment. He tends to be hypervigilant but does not process the connectedness productively, which ads to his propensity to distort. Affective arousal is likely to interfere with his reality testing and disrupt his judgment. His anger also compromises his decision-making and coping capacities. In stressful situation he becomes over-ideational and uses fantasy as a defense. Increased reality testing is highly recommended.
There is strong evidence to suggest that Mr. Freedman's long standing interpersonal difficulties are accompanied by a great deal of inner conflict. In social situations, Mr. Freedman is in continual conflict over his longing for emotional connection, yet feeling discomfort and distrust of others. He tends to be overly cautious and somewhat superficial in social situations and prefers to avoid emotional connection. He becomes quite uncomfortable when experiencing emotions and deals with this by becoming socially constrained and overly vigilant. His need for self-affirmation through gaining the approval of others often results in a further humiliation or rejection because of the very nature of a personality style that is embedded in narcissism, grandiosity, and paranoid delusion. Constant frustrations in getting his needs met result in an interpersonal behavior that is marked by anger, hostility, and contempt.
Feeling uncomfortable in dealing with any negative or ineffectual self-image, he accordingly employs denial, fantasy, and intellectualization as defense mechanisms against the,. Although he does have the inner resources to tolerate these stressors, his defenses only work up to a point and leave him prone to disorganized functioning, flawed judgment, and poor decision-making when confronted with complex or highly ambiguous situations. He as difficulty reading his environment and responding appropriately, particularly in social situations. Furthermore, his high verbal and intellectual abilities leads him to employ sophisticated yet misleading and delusional rationalizations for his problems. Given is deeply ingrained pattern of maladaptive functioning, he is vulnerable to bouts of anxiety and depression. The risk for suicide attempts must be anticipated in such a state of decompensation.
Patients such as this have a difficult time sustaining a therapeutic relationship as he is likely to employ maneuvers to test the sincerity and motives of the therapist. A major goal of therapy would be to guide Mr. Freedman into recognizing the source of his ambivalence and to reinforce a more direct and constructive means to approach his life.
There are specific therapy techniques that may be helpful for him. He would probably benefit most from supportive therapy that calls attention to his positive traits in order to shore up his confidence and self-esteem. An approach that employs the combination of behavioral modification to achieve consistency in his social behaviors, and directive cognitive techniques to confront him on his self-defeating and obstructive patterns in his interpersonal relations may pout reins on his vacillations of mood and behavior. A more exploratory and interpersonal approach to therapy must be handled cautiously, as it may awaken feelings of false hopes disappointments, and self0depcreaction that are too painful for Mr. Freedman to tolerate at this time. Furthermore, he may derive benefits from pharmacological tranquilizing agents and/r antidepressant drugs to alleviate his anxiety and depression.
Yu Ling Han, M.A.
Clinical, Psychology Intern
William D, Fabian, Jr., Ph.D.
Fictional Cross Examination of Yu Ling Han:
Dr. Han, did the testing disclose that Mr. Freedman has any anxiety whatsoever surrounding his sexual orientation? Yes or no.
--No, it did not disclose that.
Dr. Han, did the testing disclose that Mr. Freedman has any psychotic thought processes that would be consistent with the diagnosis of a psychotic disorder such as bipolar disorder, delusional disorder, or paranoid schizophrenia? Yes or no.
--No, it did not.
Dr. Han, what is your basis for saying that Mr. Freedman shows delusional thinking--his self report or the testing?
--Mr. Freedman’s self-report indicated to me that he was delusional. As I said, the testing did not disclose any psychotic thought processes.
The testing itself did not indicate that he had a psychotic disorder or a nonpsychotic paranoid personality disorder, isn't that true.
--Yes. That is correct.
Dr. Han, the MMPI includes an ego strength scale, does it not?
--Yes, it does.
Did the MMPI indicate that Mr. Freedman showed any impairment in ego strength?
--No. His ego strength was normal.
Dr. Han, did the testing indicate that Mr. Freedman suffers from any psychiatric disorder of any kind?
--No. The testing did not yield any diagnosis.
No further questions, Your Honor.