GW Psychiatric Treatment: Critique of Psychological Testing

In May 1994 I was administered a comprehensive battery of psychological tests by The George Washington University Medical Center Department of Psychiatry and Behavioral Sciences.  The testing was performed by a psychology intern named Yu-Ling Han under the supervision of William Fabian, Ph.D.

On August 25, 1994 I reviewed the eight-page test report prepared by Yu-Ling Han during a consultation with my then-treating psychiatrist, Dimitrios Georgopoulos, M.D.  Dr. Georgopoulos did not provide me a copy of the test report to keep.  On August 25, 1994, I returned the copy Dr. Georgopoulos had given me to read aloud in his office.  It was not until late June 1996 -- about two years later -- that Dr. Georgopoulos provided me a copy of the test report.

The following is a critique of the test report I prepared in the days following August 25, 1994 based on my recollection of what I read in Dr. Georgopoulos’s office.  Some of the criticisms are valid and substantial.

One oddity.  I distinctly recall that the copy of the test report Dr. Georgopoulos handed me on August 25, 1994 stated that my overall IQ as measured by the Wechsler Adult Intelligence Scale was 129.  I can recall that clearly because I remember thinking at the time, “Damn, if I had scored only one point higher, I would qualify for membership in Mensa,” an organization whose members have an IQ of 130 and above.  Yet, the copy of the test report Dr. Georgopoulos gave me in late June 1996 stated my overall IQ as 125. 

In any event, I transmitted a copy of the following critique to GW’s Medical Director Keith Ghezzi, M.D., who in turn forwarded the critique to Psychiatry Department Chairman, Jerry M. Wiener, M.D.  I may have forwarded a copy of the critique to the Washington Field Office of the FBI.
_________________________

August 29, 1994
3801 Connecticut Ave., NW
#136
Washington, DC  20008

D. Georgopoulos, M.D.
Dept. of Psychiatry
GW Univ. Med. Ctr.
2150 Pennsylvania Ave., NW
Washington, DC  20037

Dear Dr. Georgopoulos:

This communication is a follow-up of our review, on Thursday, August 25, 1994 of the psychological test summary.  This letter states my comments, critique, and concerns regarding the test report summary (“test report”) prepared by psychological intern Yu-Ling Han (“intern”).  The test report discusses the results of psychological testing performed by the intern in early May 1994, under the supervision of William Fabian, Ph.D. of the George Washington University Medical Center Department of Psychiatry and Behavioral Sciences.  The test report synthesizes the results of the psychological testing, the intern’s clinical impressions, input from my former treating psychiatrist, Dr. Suzanne M. Pitts, and statements contained in the initial assessment chart (“assessment chart”) prepared by Napoleon Cuenco, M.D., dated September 24, 1992.

The following comments are based on my recollection of the test report, which I read in your presence on August 25 and thereafter returned to you.  I was not provided a copy of the test report for my personal records.

1.  “Worst Possible Concept” Test

The intern requested that I create a drawing that depicted what I considered to be the worst possible concept that I could imagine.  I drew a picture of an exploding sun whose rays appeared to envelop and destroy the Earth.  I titled the drawing “The Death of Optimism,” and explained that the picture was intended to depict my belief that as long as there is life there is hope, and that the destruction of the Earth and of life itself would be for me the worst possible concept since it would mean the end of hope, or “optimism,” itself.


http://dailstrug.blogspot.com/2010/09/tough-jews-rich-cohen.html

It recently occurred to me that the way I depicted that particular concept might have a concrete basis in actual childhood experience.  When I was a child, my family and I used to vacation each summer in Atlantic City, New Jersey.  I can remember that on one particular vacation, I experienced a mildly serious and painful burn as a result of over-exposure to the sun.  We used to stay with friends of my father who resided at the intersection of Vermont and Oriental Avenues in Atlantic City.  The intern (Yu-Ling Han) was of Asian (“Oriental”), presumably Chinese, heritage.  Thus, the concept of “The Death of Optimism," drawn at the request of Ms. Han, may have had a concrete basis in childhood experience and, at one primitive level, may have simply signified the concerns of a small boy whose optimistic hopes for his vacation had been ruined by a bad sunburn.

One wonders to what degree this interpretation of the concrete basis of the concept relates to how I translate concrete thinking into abstract conceptualization.  Also, one wonders to what degree my interpretation of the concrete basis of the drawing either complements, corroborates, or contradicts the intern’s interpretation of the abstract content.

2.  Intelligence Testing -- Wechsler Adult Intelligence Scale (WAIS)

The intern reports a relatively high IQ of 129, but cautions that this score is heavily skewed by unusually high scores on two verbal scales.  She observes that, generally, I tested only average on the Performance Scales.  The intern then proceeds to advance an hypothesis to explain my putatively poor reality testing ability.  According to the proposed theory my poor reality testing ability, or impaired ability to read social cues, may be attributed to my relatively poor performance on the (nonverbal) Performance Scales: that my performance on the (nonverbal) Performance Scales, which tested only average, reflects a perceptual and cognitive style that is impaired.  The hypothesis advanced by the intern seems to be supported by the Wechsler (WAIS) test results, although it will be noted that none of the (nonverbal) Performance Scales, to the best of my recollection, were below average (50th Percentile).  That an individual who scores no lower than 50th percentile on the Wechsler (nonverbal) Performance Scales and whose overall IQ is measured at 129 (95th percentile) will have significant difficulties reading social cues is debatable at best.

However, significantly, the intern had available to her the results of prior IQ testing that I had provided to her.  In a memo dated May 4, 1994 (attached herewith) I detailed to the intern the results of two prior IQ tests taken, respectively, when I was age 11½ and 12½.  A review of the IQ score breakdown contained in the subject memo dated May 4, 1994 indicates a broad-based, overall above-average verbal ability.  Indeed, the verbal ability scale indicated a mental age of 19, 6½ years in advance of my chronological age of 12½.  The reading comprehension scale indicated a mental age of 17, or 4½ years in advance of my chronological age at the time of testing.  Of particular significance is the fact that two of the nonverbal scales on the IQ test administered at age 12½ indicate a very high mental age.  The map reading scale (a nonverbal scale) indicated a mental age of 20, fully 7½ years in advance of my chronological age.  The graphs scale (a nonverbal scale) indicated a mental age of 18, or 5½ years in advance of my chronological age.  Thus, the results of the IQ test administered when I was 12½ do not support the intern’s implication that I am a kind of idiot savant who performs extraordinarily well on a limited range of intellectual tasks.  Further, the prior IQ test results vitiate the hypothesis that my putatively poor reality testing ability may be linked to the fact that I uniformly score poorly on any nonverbal IQ scale.  The results from the IQ testing from age 12½ indicate an unusually high score on two of the nonverbal scales, maps and graphs, which one assumes are equally related to reality testing as any of the Performance Scales on the Wechsler (WAIS) test.  My extraordinarily high score on the map reading scale at age 12½ is utterly inconsistent with the intern’s hypothesis that when faced with a complex, real life situation I tend to become lost in a maze of details; in fact, map reading ability correlates with a general aptitude to understand and synthesize a complex set of nonverbal facts.

All of this raises a significant and troubling question.  Why did the intern attempt to confer a deceptively credible gloss on a hypothesis concerning my putatively poor reality testing ability by selectively omitting other IQ test data that were in her possession?  One wonders why the intern proposed a theory which she had to have known had no support; the memo dated May 4, 1994 that I had given to the intern, which detailed the results of prior IQ tests, renders the theory unsupportable.  It would appear that the intern was overreaching in an effort to provide a deceptively rational, objective basis for the view that my putatively poor reality testing (and seeming paranoia) can be linked to an impaired perceptual/cognitive style that can be objectively established by reference to the results of intelligence testing.

3.  Diagnoses

(a.)  The assessment chart, dated September 24, 1992, states a diagnosis of bi-polar disorder (rule out schizoaffective disorder).  I had provided Dr. Cuenco a detailed writing that summarized what appeared to be a complex delusional belief system that centered on the imagined activities of my former employer.  Despite the clear import of the writing, Dr. Cuenco made no reference whatsoever to delusional thinking in the assessment chart, although he did refer to “paranoid ideations.”

(b.)  Dr. William Fabian assigned the diagnosis Paranoid (Delusional) Disorder on the billing statement prepared in late June 1994 for the subject psychological testing.  The intern states in the test report that the results of both the MMPI and the Millon tests (both self-report surveys) failed to yield either an axis I or axis II diagnosis.  The intern states that I may have lied on the tests in order to conceal the severity of my paranoia, but does not explain why I would attempt to conceal my paranoia on testing but freely discuss my ideations with her.  In fact, on the Millon test I responded affirmatively to the test statement: “I believe I have been spied on for years.”  My response to this test question was freely available to the intern at the time she made the insupportable statement that I may have lied on the MMPI and the Millon tests in order to conceal the severity of my paranoia.

Note also that the MMPI and the Millon contain validity scores: the MMPI includes three separate validity scores, namely, a lie score, a validity score, and a correlation score.  None of the validity scores on either of the tests indicate that I lied on the tests in an attempt to conceal the nature or severity of my psychopathology.

4.  Grandiosity

(a.)  The intern refers repeatedly to my grandiosity and grandiose self image.  The intern, however, does not state the basis of her conclusion.

The test report refers to my belief that I am a victim of the jealousy of others, which belief is generally indicative of a narcissistic trend in the personality; however, it was a previous psychiatrist, Stanley R. Palombo, M.D., who told me it was his belief that I was a victim of others’ jealousy.

The intern may have viewed my unusual idea production as grandiose; she refers to my seeming attempts to impress her with my ideas.  Note, however, that the willingness to extend effort in idea production has been interpreted as an aspect of creative ego functioning.  See Parnes, S.J. “Research on Developing Creative Behavior.”  In Widening Horizons in Creativity.  Edited by C.W. Taylor.  (John Wiley & Sons: 1964).

Finally, one of my responses on the Thematic Apperception Test may have contributed to the intern’s perception that I am grandiose.  I was asked to provide a story line and description of a picture of a boy contemplating a violin.  I stated that I interpreted the picture as portraying a violin prodigy, and proceeded to describe the travails of child geniuses.  Some weeks later I discovered, accidentally, that the boy depicted in the picture (and whose identity was not disclosed at the time of testing) was in fact the violin virtuoso Yehudi Menuhin.  Thus, an instance of hypernormal reality testing--my ability to accurately perceive in the child’s face the fact that he possessed special qualities--may have been misinterpreted as an example of my grandiosity.  The intern’s deceptively credible conclusion applied to me, “paranoid, poor reality testing”--was given additional weight by her possible misinterpretation of my response on the Thematic Apperception Test.

(b.)  The assessment chart prepared by Dr. Cuenco makes no reference whatsoever to grandiosity, grandiose self image, or narcissism.  Note that I had provided Dr Cuenco a copy of an “autobiographical sketch” that might be termed grandiose.

5.  Reality Testing

The intern concluded that my reality testing ability is poor.

An independent, objective assessment of reality testing ability may be obtained by evaluation of Rorschach responses.  In one study, for example, it was concluded that the test subjects’ systematic handling of Rorschach patterns correlated “with keener awareness of peculiarities and more selective theoretical interest” which indicates a high reality testing potential.  See Boyer, L.B., et al.  “Comparisons of the Shamans and Pseudoshamans of the Apaches of the Mescalero Indian Reservation: A Rorschach Study.” Journal of Projective Techniques and Personality Assessment 28:173-180, at 178 (1964).  Another study correlated cognitive/perceptual style (and, hence, reality testing potential) to Rorschach response style.  Boyer, L.B. and Boyer, R.M. “Prolonged Adolescence and Early Identification A Cross-Cultural Study.”  In: The Psychoanalytic Study of Society, vol. 7, 95-106, at 98-99.  Gertrude R. Ticho, M.D., contributing editor (Yale University Press: 1976).

There is no indication that the intern assessed my Rorschach responses according to accepted criteria to arrive at an independent evaluation of my cognitive/perceptual style and reality testing potential.  Instead, the intern attempted to advance a theory to explain my putatively poor reality testing ability on the basis of a spurious interpretation of the IQ results available to her (see paragraph 3, above).

6.  Intellectualization

The intern emphasizes my reliance on intellectualization, an ego defense.

Intellectualization, or brooding, has been defined as “anxious or moody pondering, usually about very abstract matters.  Brooding is seen frequently in obsessive-compulsive neurotics as a thinking compulsion, a need to worry very much about apparently insignificant things.  This is a form of displacement onto a small detail and represents an attempt to avoid objectionable impulses or affects by escaping from the world of emotions into a world of intellectual concepts and words.”  Psychiatric Dictionary, 6th ed., at 106.  R.J. Campbell, M.D., ed. (Oxford University Press: 1989).

In terms of ego functioning, the primary aspect of “intellectualization” is that it, like all ego defenses, wards off ego dystonic unconscious impulses.

However, not all compulsive intellectual activity is attributable to defensive intellectualization.  In certain individuals compulsive intellectual activity may be attributed to a hyper-developed synthetic functioning, and does not result from the warding off of instinctual impulses, but is actually a libido-derived activity.  “Synthesis is considered to be a complex ego function, probably a derivative of libido, which impels the person to harmonious unification and creativity in the broadest sense of the term.  Synthesis includes a tendency 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.”  Psychiatric Dictionary, 6th ed., at 734.  R. J. Campbell, M.D., ed. (Oxford University Press: 1989).

Although normal personality functioning relies on the development of some degree of synthesis, it is believed that in certain persons the synthetic function may become hyper-developed.  “When the ego’s stability is most gravely threatened [with the loss of object libido], but it yet retains a certain measure of constructive energy its synthetic functions are immeasurably extended.”  Nunberg, H. “The Synthetic Function.”  Practice and Theory of Psychoanalysis, at 127 (1930; reprint, International Universities Press: 1948).

According to Nunberg, traumatic object loss may be a factor in the development of hypernormal synthetic functioning.  You will note that both the assessment chart prepared by Dr. Cuenco and the intern’s test report emphasizes the problem of pathological mourning (object loss) for me, which arguably, is consistent with the development of hypernormal synthetic functioning.

Unfortunately, there is no indication in the test report that the intern even considered the possibility that my intellectual activity results from libido-derived synthetic functioning.  She assumes, summarily, that my intellectual activity is the more common defensive intellectualization (and that my idea production reflected my grandiosity as opposed to a willingness to extend effort in idea production as seen in creative persons).

The intern observes my emotional flatness and, without apparent justification, associates that flatness with defensive intellectualization.  But note that while hypernormal synthetic functioning would not in itself account for the emotional flatness more commonly associated with defensive intellectualization, it is reasonable to suppose that hyper-developed synthetic ego functioning might be accompanied by isolation or splitting defenses (especially in view of the often traumatic origin of hypernormal synthetic ego functioning, as postulated by Nunberg).  Where libido-derived compulsive intellectual activity is accompanied by the ego defenses of isolation or splitting, the patient’s intellectual activity, accompanied as it will be by emotional flatness, will be virtually indistinguishable from purely defensive intellectualization.

An attempt to distinguish defensive intellectualization from libido-derived intellectual activity is not mere hairsplitting.  Synthetic ego functioning (libido-derived intellectual activity) is an essential element of reality testing ability, while the use of defensive intellectualization does not necessarily correlate with reality testing (though, of course, defensive intellectualization is associated with above-average intelligence).  The presence of hypernormallibido-derived intellectual activity is not mere hairsplitting.  Synthetic ego functioning (libido-derived intellectual activity) is an essential element of reality testing ability, while the use of defensive intellectualization does not necessarily correlate with reality testing (though, of course, defensive intellectualization is associated with above-average intelligence).  The presence of hypernormal synthetic-functioning would, however, tend to indicate high reality testing potential since synthesis, by definition, involves cognitive functions fundamental to reality testing, namely, a tendency 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.  The intern, by ignoring the possibility that my compulsive intellectual activity might reflect hypernormal synthetic functioning, and asserting, in the alternative, that my intellectual activity was simply defensive intellectualization gives, once again, a deceptively credible gloss to the proposition that my reality testing is poor.

7.  Automated Computer Interpretation

There is no indication that the intern employed automated computer personality profiling.  Several computer programs are available that will generate an automated computer interpretation of MMPI (and, presumably, Millon) profile scales.  The Mayo Clinic-Psychological Corporation system, the simplest of the available programs, generates a narrative report that concentrates on present symptomatology and emotional status; more complex programs are available that provide highly interpretative statements.  Automated computer interpretation of my MMPI and Millon test scores would provide an independent and objective evaluation of my personality, untainted by the subjective biases and intellectual limitations of an evaluator.

8.  Depression

The intern emphasizes evidence of depression in my case, and recommends that an anti-depressant be prescribed.  You will note that the MMPI (and, presumably, the Millon) includes a Depression scale.  There is no indication in the intern’s test report that the Depression scale was significantly elevated.

Further, despite the intern’s emphasis on depressive psychopathology--including the possibility of suicide--my former treating psychiatrist, Dr. Suzanne M. Pitts, repeatedly refused to prescribe an anti-depressant.  She stated that my manic or hypomanic symptoms were contra-indications for an anti-depressant.

(The intern may have based her concern regarding the possibility of suicide in my case on one of my responses to the Thematic Apperception Test (TAT).  I identified one of the TAT pictures, which depicted a woman lying in bed, as representing the actress Marilyn Monroe following a suicide attempt.  You will note that the reference to suicide in this context may not automatically signify depressive psychopathology, per se.  As Dr. Albert Rothenberg has pointed out, death is the biological and, according to Freud and others, the psychological antithesis of sexual potency.  The image of the suicidal Marilyn Monroe may therefore be an elegantly-complex metaphor for the simultaneous defensive negation of the antithetical ideas of death (suicide) and sexuality.  Additionally, this interpretation of the TAT response carries implications regarding the structure of my ego functioning, here indicating the presence of simultaneous defensive negation, a creative ego function.  See Rothenberg, A. “Janusian Thinking and Creativity.”  In: The Psychoanalytic Study of Society, 1-30, at 6-7 and 24.  Gertrude R. Ticho, M.D., contributing editor (Yale University Press: 1976) (discussing the simultaneous conceptualization of suicide and sexuality as it pertains to the genesis of both Eugene O’Neil’s play The Iceman Cometh and Einstein’s General Theory of Relativity).)

9.  Mania/Hypomania

The MMPI (and, presumably, the Millon) includes a Hypomania scale.  There is no indication in the intern’s report that the Hypomania scale was elevated, or that any of the tests were suggestive of manic-depression.  Although the intern makes a pharmacologic recommendation of anti-depressant or tranquilizer, she does not recommend a mood stabilizer such as lithium.  The propriety of nonmedical staff making pharmacologic recommendations notwithstanding, the intern’s failure to recommend lithium or other mood stabilizer indicates that she did not discern significant manic-depressive symptomatology.

You will recall that Dr. Cuenco had diagnosed me as suffering from Bi-Polar Disorder in September 1992 and Dr. Pitts prescribed lithium therefore in February 1993.

The intern does report certain symptoms, based on her clinical impressions, suggestive of hypomania, namely, loose associations and rapid, pressured speech.

You will note that the pathological symptom “loose associations” may be confused with a trait characteristic of creative persons: a drive and capacity to bring together remote associations.  See Mednick, S.A. “The Associative Basis of the Creative Process.”  Psychological Review 69: 220-232(1962).

With regard to rapid speech one wonders whether this is a pathological symptom or simply a reflection of the verbal fluency that one might expect from an individual whose verbal IQ was measured on the Wechsler test (WAIS) at the 99th percentile.

The essential point is that one of the basic flaws of the intern’s test report is its utter failure to engage in any differential diagnosis.  “If he produces a lot of ideas and states them quickly, he’s automatically a grandiose hypomanic” (not a highly creative and verbally-fluent individual).  “If he thinks a lot about his situation, he’s a defensively intellectualized person with poor insight who cannot face up to the real source of his problems" (not a fellow with extraordinary insight who is compelled by the nature of his ego functioning to understand, reconcile conflicting ideas, and seek for causality).

Need one inquire into the source of the intern’s observation “He devalues people?”

10.  Gender Confusion/Shame Regarding sexual Orientation

The assessment chart prepared by Dr. Cuenco states as one of its three central recommendations for therapy that I work on my concerns regarding my sexual orientation.  Dr. Cuenco’s recommendation suggests that I am either a shame-ridden homosexual or a shame-ridden heterosexual with poor gender identity.

The MMPI (and, presumably, the Millon) contains a Masculinity/Femininity Scale.  The intern’s report does not indicate a score on this scale suggestive of either gender confusion or shame regarding sexual orientation.

11.  Social Phobia/Introversion

My former treating psychiatrist, Dr. Pitts, had recommended the neuoleptic Haldol to help me overcome what she perceived to be severe social phobia.  She stated that Haldol would permit me to initiate social interaction with others without being overcome by paralyzing social fears.  Dr. Pitts’ recommendation of a neuroleptic, a drug frequently prescribed to psychotics, to ease my interaction with others indicates that she must have viewed me as suffering from a social phobia of considerable severity.

The MMPI (and, presumably, the Millon) includes a Social Introversion Scale.  There is no indication in the test results that the Social Introversion Scale is elevated.  One would have assumed, based on Dr. Pitts’ pharmacologic recommendation, that this scale would have been quite high.

12.  Ideas of Reference and Delusions

My former employer justified his termination of my employment on the grounds that my complaint of harassment was based on ideas of reference, suggestive of a serious mental disorder.

Although the MMPI does not contain a scale than measures ideas of reference directly, the test does apparently permit some kind of assessment of ideas of reference.  “The MMPI items range widely in content, covering such areas as: health, psychosomatic symptoms, neurological disorders, and motor disturbance; sexual, religious, political, and social attitudes; educational, occupational, family, and marital questions and many well-known neurotic or psychosomatic behavior manifestations, such as obsessive or compulsive states, delusions, hallucinations, ideas of reference, phobias, and sadistic and masochistic trends.”  Anastasi, A. Psychological Testing, 4th ed., at 497 (MacMillan: 1976) (emphasis added).

The intern’s report does not indicate that the MMPI results were consistent with the presence of either delusions or ideas of reference, despite the fact that, apparently, the MMPI permits assessment of both these disturbances.

13.  Factual Distortions and Overbroad Generalizations

(a.)  The intern’s report contains several factual distortions, including the odd, if not bizarre, confabulation that I had reported terminating my work with a previous therapist following a dispute concerning that therapist’s interpretation of an MMPI test.  The MMPI in question was administered by Mr. John Brennan at the Spokane Community Mental Health Center in Washington state in April 1980.  I terminated my work with that therapist in August 1980 upon transferring from a law school in Spokane to one in Philadelphia, Pennsylvania.  One wonders how the intern’s factual distortion about my previous experience with psychological testing might relate to a possible underlying, subjective bias concerning me.  (It is noted, incidentally, that the previous therapist who administered the MMPI in April 1980 thought that I had "faked crazy.”)

(b.) The intern’s report includes numerous overbroad, generalized conclusions.  For example, the test report states that I have a fear of ridicule in my social interactions.  I suspect that the intern based this conclusion on my response to one of the Rorschach cards that I identified as “a mask of Shakespeare being worn by Dr. Jerry M. Wiener, who is laughing at me contemptuously under the mask.”  The concern regarding ridicule, in the context of my association to Dr. Wiener, relates specifically to my relations with authority figures and to my internal object relations vis-à-vis my superego.  Indeed, the fear of ridicule by an authority figure, as in this context, may suggest Oedipal conflict or the presence of unmetabolized superego precursors resulting from traumatic object loss--an interpretation far afield of the intern’s generalized extrapolation.

Sincerely,

Gary Freedman