Psychiatric Assessment: George Washington University Medical Center, 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
____________________________________________________________________________

The George Washington University Medical Center
Washington, DC
Department of Psychiatry and Behavioral Sciences

Psychological Evaluation

NAME: Gary Freedman
DOB: 10-27-64 [sic]
EDUCATION: Law Degree
DATES EXAMINED: May 4, 5, & 11 [1994]
REFERRED BY: Suzanne Pitts, M.D.

REFERRAL QUESTION:

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.]

TESTS ADMINISTERED:

Bender Visual Motor Gestalt Test
Draw-A-Person
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

PRESENTING PROBLEM:

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.

BACKGROUND INFORMATION:

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.

BEHAVIORAL OBSERVATIONS:

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.

TEST REULTS:

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 gad 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 f 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.

CONCLUSION:

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.

[signed]

Yu Ling Han, M.A.
Clinical, Psychology Intern

[signed]

William D, Fabian, Jr., Ph.D.
Assistant Professor

******************************************

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.

______________________________

Comment by Gary Freedman on October 21, 2009 at 11:51am

When we hear someone say that he is a victim of covert surveillance our immediate reaction is that the person is paranoid. Generally, only paranoid people claim to be victims of covert surveillance. The claim "I am being watched" will tend to provoke the reaction "You are paranoid!"

But let us assume that a person is in fact a victim of covert surveillance. How would he know that he is being watched? What powers would the individual have to possess to appreciate the fact that he is under surveillance? Would the individual require some superhuman powers? Or would the individual only need certain unusual -- but psychologically recognized -- personality factors?

The following is a personality profile of a person who might be able to detect that he was being surveilled covertly. The individual who is sensitive to covert clues in the environment might be unusual, but not necessarily paranoid.

REALITY TESTING -- Protension

Subject exhibits a high level of ego strength. He is vigilant, suspicious, skeptical, distrustful, and oppositional (protension). Subject's orientation to the environment contrasts with the following factors associated with a low level of ego strength: trusting, unsuspecting, accepting, unconditional, easy (alaxia).

http://en.wikipedia.org/wiki/16_Personality_Factors

REALITY TESTING -- HYPERVIGILANCE -- NEED FOR INTELLECTUAL MASTERY

Subject accepts id drives and fears, and handles them through a strong ego, which is constantly engaged in reality testing. Subject reaches out for every form of clue in his environment and retains almost every bit of information, which evidently helps to satisfy his need for intellectual control of his relationships with the outer world. Subject is sensitive to every nuance of reaction from the outer world as it pertains to him. Myden, W. "An Interpretation and Evaluation of Certain Personality Characteristics Involved in Creative Production." In: A Rorschach Reader at 164-65. Sherman, M.H., ed. (New York: International Universities Press, Inc., 1960). The individual's responses on the Rorschach test would be detailed, expansive, and unconventional. He might be accused of "showing off" by the Rorschach test examiner.

REALITY TESTING -- SOCIAL SENSITIVITY -- FEAR OF CONTAMINATION AS EGO STRENGTH -- IDENTITY DISTURBANCE -- DEPRESSIVE PSYCHOPATHOLOGY

Subject tends to be a non-joiner, but is socially sensitive. He is fearful of undue influence from others (according to Hartmann, the fear of contamination from others can be a product of ego strength) and it may be his very sensitivity to what others are thinking and feeling that makes him shun too much company. Subject seems to have only a tenuous sense of his own identity. Subject's sensitivity together with his depressive psychopathology disposes him to very easily identify himself with others; and, lacking certainty in his own uniqueness, feels an especial need to assert and preserve what he feels to be precarious. Storr, A. The Dynamics of Creation at 190 (New York: Atheneum, 1972).

REALITY TESTING -- SOCIAL SENSITIVITY -- CAUSE -- DISTURBED DEVELOPMENTAL ENVIRONMENT

Subject is unusually sensitive to implicit messages contained in the communications of others. Subject's sensitivity results from his adaptation to a disturbed developmental environment in which there were often remarkable discrepancies between what family members said they felt and what they actually felt. Rothenberg, A. Creativity and Madness at 12 (Baltimore: The Johns Hopkins University Press, 1990).

REALITY TESTING -- HYPERVIGILANCE -- ADAPTIVE PARANOIA -- CAUSE -- DISTURBED DEVELOPMENTAL ENVIRONMENT

Subject's interaction with exploitive and manipulative persons in a disturbed developmental environment forced him into an adaptive paranoid attitude. Subject's early environment demanded constant wariness, the habit of observation, and attendance on moods and tempers; the noting of discrepancies between speech and action; a certain reserve of demeanor and automatic suspicion of sudden favors. Shengold, L. Soul Murder at 244-45 (New Haven: Yale University Press, 1989).

REALITY TESTING -- SPLITTING -- OBSERVING/EXPERIENCING EGO -- SCIENTIFIC APPROACH TO THINKING

Subject exhibits a split between the observing ego and the experiencing ego (a vertical split) of unusual magnitude, which he is able to put to adaptive, creative use. The strength and pervasiveness of his isolative defenses do resemble what is found in those who have to ward off the overstimulation and rage that are the results of child abuse. Shengold, L. Soul Murder at 83 (New Haven: Yale University Press, 1989).

REALITY TESTING -- SCIENTIFIC APPROACH TO THINKING -- SENSITIVITY TO DETAILS/PECULIARITIES

Subject possesses greater creative potential than many of his peers; he has greater capacity for regression in the service of the ego and an ego-controlled availability of primary process thinking. Subject's mental approach is unusually systematic (as disclosed by his detailed and expansive responses on Rorschach testing); he handles objective data with an especially keen awareness of peculiarities and selective theoretical interest, which indicates a high reality testing potential. Subject's easy access to infantile fantasies and experiences suggests a capacity for creative integration of the alien past into the life cycle, a capacity that lies beyond mere disruptive psychopathology. Ducey, C. "The Life History and Creative Psychopathology of the Shaman: Ethnopsychoanalytic Perspectives." In: The Psychoanalytic Study of Society. Vol. 7: 173-230 at 176. Gertrude R. Ticho, M.D., contributing ed. (New Haven: Yale University Press, 1976).

SYNTHETIC FUNCTIONING -- CAUSE/EFFECT THINKING -- NEED TO RECONCILE INNER/OUTER WORLDS -- NEED FOR INTELLECTUAL MASTERY

Subject's synthetic functioning, a libido-derived function, is highly developed, and impels him to harmonious unification and creativity in the broadest sense of the term. Subject's highly-developed synthetic functioning impels him to simplify, to generalize, and ultimately to understand--by assimilating external and internal elements, by reconciling conflicting ideas, by uniting contrasts, and by seeking for causality. Campbell, R.J. Psychiatric Dictionary at 734 (New York: Oxford University Press, 1989, 6th ed.).

SYNTHETIC FUNCTIONING -- AUTOPLASTIC ADAPTATION TO OBJECT LOSS -- DEFENSIVE WITHDRAWAL OF EMOTIONAL INVESTMENT IN MOTHER

The unusual extension of subject's synthetic function, beyond conventional parameters, may be viewed as an autoplastic adaptation to a severe stressor, namely, traumatic loss of the maternal object. Nunberg, H. "The Synthetic Function." Practice and Theory of Psychoanalysis at 127. (New York: International Universities Press, 1948).

INTELLECTUAL ABILITIES -- CREATIVE POTENTIAL -- SOCIAL DIFFICULTIES

Subject exhibits a highly-developed verbal fluency, an unusual capacity to bring together remote associations, and the ability to extend effort in idea production (ideational fluency). Guilford, J.P. The Nature of Intelligence (New York: McGraw-Hill, 1967); Mednick, S.A. "The Associative Basis of the Creative Process." Psychological Review 69: 220-232 (1962); Parnes, S.J. "Research on Developing Creative Behavior." In: Widening Horizons in Creativity. Edited by C.W. Taylor. (New York: John Wiley & Sons, 1964).

Subject's intellectual abilities are so highly-developed that they have been mistaken, even by psychiatrists, as psychotic symptoms in the form of pressured, rapid speech; flight of ideas; and loose associations. See Psychiatric Assessment Chart (Napoleon Cuenco, M.D., St. Elizabeths Hospital Residency Training Program), George Washington University Department of Psychiatry (September 1992) (Daniel Tsao, M.D., Attending Physician). . Comment by Gary Freedman on October 19, 2009 at 10:03am Delete Comment FACT: Dr. Cuenco diagnosed me with bipolar disorder in September 1992. Three other psychiatrists later diagnosed me with paranoid schizophrenia: Dr. Dimitrios Georgopoulos (February 1996); Dr. Albert H. Taub (January 1999); and Dr. Betsy Jane Cooper (March 2004). Note that bipolar disorder (a mood disorder) is a rule out for paranoid schizophrenia; the two diagnoses are inconsistent. It would be extremely rare or impossible for a person to go from bipolar disorder to paranoid schizophrenia. One can go from bipolar disorder to schizoaffective disorder, however. But either Dr. Cuenco was incorrect in his diagnosis of bipolar disorder or Drs. Georgopoulos, Taub, and Cooper were incorrect in their diagnosis of paranoid schizophrenia.

FACT: I underwent comprehensive psychological testing at GW in May 1994. The testing did not disclose any gender-identity disturbance. The Minnesota Multiphasic Personality Inventory includes a masculinity/femininity scale that specifically measures gender disturbance; the scale was normal. None of the other tests revealed any gender-identity disturbance.

FACT: Note that there is no evidence in the assessment chart written by Dr. Cuenco in September 1992 that Dennis M. Race, Esq. (202 887 4028) told me, at my job termination on October 29, 1991, that he had consulted with a psychiatrist who determined that I was paranoid and potentially violent. In fact, I did not learn of that psychiatric consultation until late December 1992 when I received Akin Gump's responsive pleadings (dated May 22, 1992) in Freedman v. Akin Gump, et al. filed with the DC Dept. of Human Rights.