February 10, 1994
[minor revisions: 10/5/94]
3801 Connecticut Avenue, NW
Washington, DC 20008
Social Security Administration
Office of Disability and
1500 Woodlawn Drive
Baltimore, MD 21241-0001
RE: Social Security Disability Claim No. xxx-xx-xxxx
This letter sets forth, with respect to the above-referenced matter, the treatment recommendations of my current treating psychiatrist, Dr. Suzanne M. Pitts, at the George Washington University Medical Center, Washington, DC.
9/24/92: Assessment Chart
Dx: Bi-polar disorder; rule our schizoaffective disorder
Rx: Lithium possibly also neuroleptic
Narrative discusses facts relating to affective disorder; no history taken of paranoid ideation or delusions despite my (a) statements at evaluation indicating presence of delusions and (b) written materials detailing a complex delusional system relating to my belief that I was being surveilled by my former employer
(1) Therapy with Dr. Pitts commences
10/26/92 - 1/12/93
(2) Dr. Pitts does not mention drugs at all. (But see Rx, above).
[According to Dr. Pitts I was psychotic when I wrote the following pleading dated January 5, 1993:
(3) Dr. Pitts states that she will be scheduling an EEG and will be prescribing medication.
(4) Dr. Pitts prescribes lithium. Initial dosage 300 mg/day.
2/9/93 - 2/26/93
(5) continual arguments with Dr Pitts about my belief that I do not have manic symptoms and that lithium is not indicated (my high level of sustained hostility is inconsistent with any therapeutic benefit from lithium).
(6) Dr. Pitts states repeatedly, that I have manic symptoms which feature, prominently, mood swings and manic linkages.
(7) Dr. Pitts ascribes my interpersonal difficulties with coworkers at Akin Gump in part to mood swings, and states that the reason why coworkers may have said they were frightened by me is my mood swings and that I may not even be aware of the manic quality of my behavior (note that the assessment chart expressly states that my affective state has never gone beyond hypomania).
(8) My letter to Dr. Pitts dated February 22, 1993 Re: coworkers’ fear of me was apparently written in response to Dr. Pitts' statements to me about how my manic symptoms arouse fear in others.
(9) At one session Dr. Pitts read to me a passage from a psychiatric journal that discussed the linkage of ideas as a symptom of mania that she has observed in my case.
(1) I advised Dr. Pitts that one of my chief concerns about lithium was that I felt it sapped my energy; I do not expressly recall complaining of depression.
(11) Throughout February there was continued self-referential thinking as evidenced by a letter that I wrote to Dr. Pitts concerning hidden meanings I discerned in a telephone conversation with my sister: see letter dated 2/16/93 re: telephone conversation with my sister on 2/9/93
(12) Letter to Dr. Pitts dated 2/16/93 includes as an appendix a writing titled: “Draft letter to D.C. Certification Board in Neurology & Psychiatry” - a veiled threat to institute a complaint against Dr. Pitts. My writing of the letter suggests a high degree of anxiety, hostility and aggression inconsistent with any improvement on lithium. (Dr. Pitts’ handwritten notes dated 8/26/93 make clear that she views letters of complaint about the conduct of therapy a pathological symptom. See paragraph 16).
(12a) We may justifiably conclude that if I derived any therapeutic benefit from lithium, that improvement could have been observed by Dr. Pitts only in the three sessions after the hostile and aggressive letter dated 2/16/93 and before the cessation of the lithium on 2/26/93; those three sessions being 2/19/93, 2/22/93, and 2/26/93, hardly enough time to infer improvement attributable to lithium. (And, in fact, see paragraph 13.)
2/26/93 (I begin tapering dosage)
(13) I advise Dr. Pitts that I intend to stop taking lithium, which I do. My dose at that point was 600 mg/day. Dr. Pitts states that she wants me to take a lithium assay. When I advise her that a lithium assay would serve no purpose since I have no intention of taking the drug any longer Dr. Pitts states: "I want to find out whether you are actually taking the lithium.” Dr. Pitts’ suspicion about whether I was actually taking the lithium is incontrovertible evidence that she saw no objective evidence of any therapeutic improvement or observable side effects. (Indeed, Dr. Pitts’ handwritten notes dated 8/26/93 are consistent with an ambiguous response to Lithium, neither therapeutic nor toxic: “Are you aware he decided to stop taking his lithium after only about 4-6 weeks despite my recommending that he continue it.” Note that I had been taking the Lithium for 18 days--from 2/9/93 to 2/26/93 NOT 4-6 weeks). In fact, I had been taking the lithium as prescribed. (Also, note Dr. Pitts’ lack of trust).
(13a) I took the lithium assay as directed by Dr. Pitts, on 2/26/93; the results are on file at GW as part of my medical records. (As you will know, a serum level of 0.6-1.2 mEq/l is considered the therapeutic range for lithium and that, generally, a dose of at least 900 mg/day is required to achieve this serum level. My highest does was 600 mg/day.)
1/19/93 - late August 1993
(14) sporadic references to neuroleptics. Dr. Pitts made no specific recommendations regarding a neuroleptic.
[According to Dr. Pitts I was psychotic when I wrote the following pleading dated July 27, 1993:
(15) Dr. Pitts give me handwritten notes, dated 8/26/93, written in contemplation of a telephone conference call with my sister to discuss the prescription of the neuroleptic, Haldol. This is the first time that Dr. Pitts makes a specific recommendation regarding a neuroleptic. (But see Rx of 9/24/92).
(16) Dr. Pitts’ handwritten notes refer to my sending out letters to various parties including the American Psychological Association and the D.C. Medical Board complaining about my past and current treatment; apparently, Dr. Pitts views such letters as evidence of psychopathology since her concerns are stated in notes relating to the prescription of a neuroleptic. Dr. Pitts’ comments in the notes dated 8/26/93 are an implicit admission that she interpreted my letter dated 2/16/93, written while I was taking lithium (see paragraph 12), as an act of hostility and aggression inconsistent with an improvement in my case. (But see paragraph 26, where Dr. Pitts on 2/7/94 said she saw improvement in my case while I was on lithium).
(17) Telephone conference call with sister and Dr. Pitts. Sister mentions that, years before, I had derived therapeutic benefit from a tranquilizer (Ativan). Dr. Pitts states that my paranoia is a contraindication for a minor tranquilizer: that a minor tranquilizer, such as Ativan, might trigger a serious outbreak of paranoia.
(17a) Dr. Pitts does not state that the minor tranquilizer Clonopin would be an exception to her concern that a minor tranquilizer might trigger a serious paranoid episode, or that she might consider prescribing Clonopin.
9/93 - December 1993
(18) Dr. Pitts does not mention drugs more than sporadically.
(19) Dr. Pitts recommends a neuroleptic following my narrative that focused exclusively on seemingly paranoid, self-referential ideation.
(2) I ask Dr. Pitts how a neuroleptic would help me. She states that it would help me with my interpersonal difficulties; that my job termination was attributable to a possible worsening of my (presumably paranoid) symptoms in October 1991. (Note that a totally different rationale prompted Dr. Pitts’ lithium prescription. See paragraph 7).
When I ask her why I was terminated she stated: “For the reasons stated,” When I asked her what were the reasons stated, she said “The reasons that they stated.” [Earlier in the year, however, in February 1993, Dr. Pitts had attributed my interpersonal difficulties to the target symptoms of lithium: that I had manic outbursts that I was not aware of, which frightened my coworkers. At this session Dr. Pitts attributed my interpersonal difficulties to the target symptoms of a neuroleptic (presumably paranoid ideation, as suggested by her recommending a neuroleptic following my seemingly paranoid narrative. See paragraph 19)].
(21) I ask Dr. Pitts whether she would now prescribe lithium. She responds that she would not prescribe lithium now because lithium did not work. (Compare Dr. Pitts’ handwritten notes dated 8/26/93 that indicate neither therapeutic nor toxic side effects: “Are you aware he decided to stop taking his lithium after only about 4-6 weeks (sic, the actual period on Lithium was 18 days, from 2/9/93 to 2/26/93--NOT 4-6 weeks] despite my recommending that he continue it.”) When I point out that I had not even reached a therapeutic serum level on lithium and therefore she could not have determined the drug’s effectiveness she said nothing. (Note that Dr. Pitts was able to come up with an answer--about 6 weeks later, on 2/7/94. See paragraph 26).
(22) She said that since Lithium had not worked, she was now moving onto the next level, a neuroleptic. (Note that lithium and Haldol are drugs of a different class, with different target symptoms. In effect, Dr. Pitts is saying “Lithium didn’t cure your mania, so we’ll now try Haldol to cure your paranoia.” But if my interpersonal problems are attributable to mania, how will Haldol help me? Note also that the assessment chart of 9/24/92 places primary emphasis on my purported mania or hypomania).
(23) Dr. Pitts gives me product information concerning Clonopin. But see paragraph 17a.
(24) I tell Dr. Pitts that she had previously stated that she would not prescribe Prozac because Prozac might trigger a serious manic episode and yet she is willing to prescribe Clonopin despite her statement on 8/26/93 that a benzodiazepine tranquilizer (a class of drugs that includes Clonopin) might trigger a serious paranoid episode. Dr. Pitts stated that she would monitor the Clonopin closely, and explained that her concerns about a benzodiazepine (a class of drugs that includes Clonopin) and Prozac--that each of the drugs could trigger either a paranoid or manic psychosis, respectively--had a facial similarity only; her respective concerns about Prozac and Clonopin were fundamentally different because of the different half-lives of the respective drugs.
(25) Dr. Pitts recommends a neuroleptic in response to my complaint that I have made no progress in therapy.
(26) I state that Dr. Pitts had lied about the lithium on 12/20/93; that she had said the drug did not work despite the fact that I had not reached a therapeutic serum level. Dr. Pitts states that when she said the lithium had not worked she had meant the following: a drug may have both a therapeutic and toxic effect, that in fact she had discerned improvement in me while I was on lithium (but see paragraphs 5, 11, 12, 12a, 13, and 16), but that I did not tolerate the drug well (but see paragraph 10). (Also, compare Dr. Pitts’ silence on the issue of lithium [at paragraph 21] about six weeks earlier).
She added that my lithium dose of 600 mg/day was sufficient to obtain a therapeutic effect and that, in fact, she has one patient who is on a maintenance dose of 300 mg/day.
(27) When I ask Dr. Pitts how a neuroleptic will help me, she states that it would help me better tolerate coworkers’ annoying behaviors (compare prescribing morphine to solve the problems of a battered wife). But compare Dr. Pitts’ rationale for lithium--that lithium will moderate my manic behaviors, frightening to others (see paragraph 7).
(28) When I tell Dr. Pitts that she simply wants to remove my seemingly paranoid ideation, she denies any such motivation (but see paragraph 19) and states that a neuroleptic would not necessarily alter my paranoid ideation but that it would help me better cope with environmental stress (but see paragraph 7).