GW Psychiatric Treatment: Letter 9/6/95

September 6, 1995
3801 Connecticut Ave., NW
Washington, DC 20008-4530

D. Georgopoulos, M.D.
GW Univ. Med. Ctr.
Washington, DC 20037

Dear Dr. Georgopoulos:

This communication reviews and discusses issues raised at the consultation on Wednesday, August 20, 1995.

PATIENT'S REPORT:

[The patient reads the text of a letter, dated September 1, 1995, addressed to the U.S. Attorney for the District of Columbia, that summarizes the patient's psychiatric treatment history at the George Washington University Medical Center.

The letter 1/ includes the following summation:

Pt. presented in September 1992 with symptoms that fulfilled the criteria of a major affective disorder: bipolar disorder NOS (DSM-III-R 296.70) with mood congruent psychotic features, including “paranoid ideations which occasionally bordered on a delusional level.” Pt.'s manic-depressive symptoms, including unstable mood, pressured and rapid speech, flight of ideas, and looseness of associations, significantly affected his functioning in a pervasive manner. Medical therapy (lithium) was initiated in February 1993, 12 weeks (3 months) following commencement of out-patient care (on October 26, 1992), and continued during the period February 9, 1993 until about February 26, 1993, when pt. refused to continue the medication. Pt.'s delusional system was deemed largely irrelevant by his assessing and treating psychiatrists and his attempts to discuss his delusional system were dismissed by his treating psychiatrist as a “power play.” In August 1993, pt. filed a complaint against his psychiatrist with the D.C. Board of Medicine, at which time pt.'s paranoia, formerly deemed occasionally delusional, was termed “crippling” by the psychiatry department chairman. Within days of the Pt.'s filing the complaint, the treating psychiatrist recommended a course of the anti-psychotic Haldol. In May 1984 pt. was administered a battery of standard psychological tests, which failed to yield either an Axis I or Axis II diagnosis, including either bi-polar disorder (DSM-III-R 296.70) or delusional (paranoid) disorder (DSM-III-R 297.10). Pt. was not administered any tests specifically designed to assess psychosis or paranoia, such as the Wisconsin Scales of Psychosis Proneness. Pt. lied on the tests in order to conceal the nature and severity of his delusional (paranoid) disorder (DSM-III-R 297.10). The test report does not state that pt. lied to conceal the nature and severity of bi-polar disorder (DSM-III-R 296.70), the symptoms of which illness were determined by the assessing psychiatrist, in September 1992, to “have been significantly affecting his functioning in a pervasive manner.”

The patient proceeds to discuss, at the consultation on August 30, 1995, inconsistencies in his psychiatric treatment history and infirmities in his assessment chart. The psychiatrist is silent throughout the reading of the letter and the patient's subsequent discussion. The patient begins to focus on a particular statement in the chart that characterizes the patient's symptoms as mood congruent psychotic features.]

PATIENT:

If we assume as a given that my delusions have been constant, stable and absolutely unchanged since 1988, then you have to assume one of two things—and you are limited, it seems to me, to one of these two things. First, assuming I suffer from bi-polar disorder, you have to assume that my delusions are sometimes mood incongruent: mood swings plus constant ideations means that sometimes the prevailing mood will fit the ideations and at other times the opposite mood will not fit the constant ideations. Or, once again, assuming I am bipolar and assuming constant delusions that are in fact exclusively mood congruent, then you have to assume that my mood has been stable since 1988—that my bipolar disorder involves extraordinarily slow cycling, with my current manic phase having lasted continuously since at least late October 1988.

[In effect, the patient is saying:

mania/depression – fixed delusions = occasional mood incongruent psychotic features (i.e., the fixed delusions might be congruent with either the mania or depression, but not both, or, alternatively,

fixed delusions – mood congruent psychotic features = constant mood (presumably manic) since inception of delusional system in 1988

It is at these particular comments that the psychiatrist seems to become agitated, cuts off the patient and in effect refuses to discuss the patient's reasonable and astute observations regarding an assessment chart that had been carefully reviewed by a staff of psychiatrists at a case assessment conference in September 1992. The patient has, in effect, called into question the conclusions of the Medical Center's psychiatry staff, or “social system,” an act that is, for this psychiatrist, forbidden. (“Everybody has to agree with me, nobody can disagree with me!”)

(It may also be that the abstract and unusual nature of the patient's comments aroused anxiety in the psychiatrist. See Letter to Dr. Georgopoulos, dated June 1, 1995.]


PSYCHIATRIST'S RESPONSE:

Why are you so concerned with what people say about you? We have talked about this before—that you are too concerned with what people say about you. 2/ The assessment chart was done three years ago; it relates to things that were done three years ago. What is said in the chart has nothing to do with your current treatment. When we started I said we would put the chart aside, and give everything a fresh look.

[A brief time later, the psychiatrist—despite having, only moments before, seemingly dispensed with the chart and having admonished the patient to move on and forget the chart—proceeds to retrieve the chart from atop his desk, scan the chart, and read the following comments, and only these comments, relating to the patient's social isolation.]

PSYCHIATRIST:

It says here that you feel people tend to be paranoid about you and trap you in double-binds; we've talked about that here. You feel lonely, isolated and hopeless.

INTERPRETATION:

With stunning regulatory the psychiatrist filters the patient's reports in such a way that the psychiatrist's interpretations repeat again and again, from session to session, the same fundamental theme, or progression, that seems to be of paramount existential concern to him.

As is so typical the psychiatrist initially drains third parties' verbal reaction to the patient of any behavioral or aggressive component. That a previous psychiatrist subjected the patient to unnecessary blood tests for a needless lithium prescription for nonexistent bipolar disorder, as diagnosed by the assessment chart, is irrelevant. That the same previous psychiatrist repeatedly recommended in a coercive manner that the patient take anti-psychotic medication, which may have caused irreversible side effects, for a supposed paranoid illness that involved mere ideations with no significant behavioral or affective component, is irrelevant. The psychiatrist depicts the assessment chart as a collection of benign statements—mere words—rather than a guide, or rationalization for a questionable and needlessly intrusive treatment protocol, which ultimately may have been unconsciously determined by the assessing psychiatrist's defensive reaction to the patient (See attached letters to Dr. Pitts, dated June 4, 1993 and June 20, 1994). For the psychiatrist, others' statements about the patient are seen strictly as a verbal representation of ideas; having been denuded of any behavioral, aggressive, or affective component, the ideas carry no consequences. Whereas the patient's mere ideas at times seem, in some magical fashion for this psychiatrist, to carry a kind of danger as though the patient's ideas were tinged with a supra-ideational potency. A paraphrase of an allegation made by the patient's former employer indicates that this form of magical thinking may be a recurring feature of the patient's interpersonal difficulties: “Claimant's ideas rendered him potentially violent.”

The psychiatrist's statement “Why are you so concerned with what people say about you?” carries a subtext that indicates that the psychiatrist needs to preserve the image of the social system as absolutely non-aggressive, while simultaneously defensively implying that the patient's concerns are rooted in the patient's hypersensitivity or weakness.

The psychiatrist then proceeds, in a progression typical for him, to focus on the patient's social isolation: "It says here that you feel people tend to be paranoid about you and trap you in double-binds; we've talked about that here. 3/ You feel lonely, isolated, and hopeless.”

The psychiatrist's fundamental existential concern may be expressed in the following metaphoric formula, which encapsulates his anxieties with respect to questioning authority, defying the social system, and his fears of consequent social isolation. 4/ Like a priest rebuking a blasphemer, it is as if the psychiatrist were saying to the patient week after week, by means of psychiatric rationalizations:

It is because you question the community of Christ that you are cut off and isolated from the community of Christ, which provides succor and comfort to those who, like myself, do not question. This is why you suffer eternal torment in the form of loneliness, isolation and hopelessness. You question the community, therefore you suffer.

The metaphoric allusion to Christianity is particularly apt and elegant. The psychiatrist's absolute inability to appreciate the effects of defamation, whether in the form of rumors or accusations by peers that the patient is potentially violent or homicidal or, more subtly but no less spuriously, that he suffers from a grave mental illness that can only be remedied chemically – surely a form of psychiatric character assassination--points eerily to a chilling correspondence between the psychiatrist's thought process and the psychology of the anti-Semite. See Letter to Dr. Georgopoulos, dated August 8, 1995, regarding the psychiatrist's inability to cope with the concept of aggressive defamation.

The anti-Semite denies aggression directed at the Jew, and depicts the Jew as the dangerous aggressor (or weak and hypersensitive castrate). Grunberger, B. “The Anti-Semite and the Oedipal Conflict.” Int'l J. of Psychoanalysis 45: 380-385; 381, 384 (1964). So it is that the anti-Semitic message – and throughout the ages aggressive libel has been one of the preferred vehicles of anti-Semitic aggression—is protected, while the object of the libel, the Jew, is cast down by “The Word.” “Why, Jew, do you worry so much what people say about you?”

Why, indeed? Perhaps it is only fitting that the Jews – the so-called “People of the Book” – have, since antiquity, been the only people to have been consistently persecuted by means of a literary genre. “Thus, in 270 B.C. the Egyptian priest Manetho published, in Greek, a 'History of Egypt,' which [one scholar] calls 'the first written anti-Semitic piece to come down to us from antiquity.' It created an influential new genre, full of the most atrocious lies and the most absurd libels that formed the defamatory ideology of Jew hatred that became an idee fixe in the culture of Christendom.” Bernstein, R. “Spanish Model for a Final Solution.” The New York Times, August 23, 1995, p. C16.

PATIENT'S REPORT:

The chart says “rule out schizoaffective disorder.” Have you done that? Have you been able to rule out a schizoaffective disorder in my case?

PSYCHIATRIST'S RESPONSE:

Schizoaffective disorder is a possibility. We could look at that as a possibility. You are socially isolated, so that illness might apply. Also, schizoaffective disorder would include your delusions.''

INTERPRETATION:

Any experienced clinician, knowledgeable in psychiatric nomenclature, would find the psychiatrist's comments regarding the applicability of the diagnosis “schizoaffective disorder” incomprehensible and ludicrous.

It is observed at the outset that the results of psychological testing administered to the patient in May 1994 failed to yield either an Axis I or Axis II diagnosis. Further, the testing, which was deemed valid, failed to reveal any psychotic thought processes. If the patient is schizoaffective, we can therefore add that to the list of illnesses that the patient was able to conceal in the testing, a list that currently includes bipolar disorder, delusional (paranoid) disorder, and (if one assumes the appropriateness of a previous psychiatrist's diagnostic speculation) schizotypal disorder. Given the putative dearth of revealing test responses, one wonders how the patient's test report could amount to anything more than a single blank page!

It should not come as a surprise that of all the symptoms of schizoaffective disorder, the psychiatrist immediately focused once again on the patient's social isolation, coincidentally the one symptom the attribution of which may satisfy the psychiatrist's own projective need, namely, his own concerns regarding fear of social isolation. See Letter to Dr. Georgopoulos, dated July 26, 1995, discussing the psychiatrist's apparently defensive misattribution to the patient that the patient had complained of being isolated by coworkers at a previous place of employment, when in fact the patient had not been socially isolated.

An experienced clinician would observe that the patient's social isolation, unlike that of the patent suffering from schizoaffective disorder, does not stem from a pathologically-impoverished social sense. This patient, though isolated, is unusually socially sensitive, open to social interaction, has been characterized by peers and employers as “charismatic” or “inspiring,” possesses a keen sensitivity to verbal and nonverbal communication, does not experience debilitating social anxiety, and, oddly, maintains enduring and stable positive social feelings for persons from the past whom he has not seen in years. Indeed, a federal law enforcement agent told the patient in December 1994: “I don't understand why you are so socially isolated. You seem like a friendly guy.” (Apparently, the psychiatrist has blocked out any recollection of the agent's comments and the diagnostic significance of the patient's interaction with an unfamiliar person—in a stressful milieu, no less. See Letter to Dr. Georgopoulos, dated July 17, 1995, regarding the psychiatrist's inability to integrate the patient's experience with the Secret Service agent into the psychiatrist's overall concept of the patient.)

Applying the psychiatrist's simplistic rule of construction, namely, the interpretation “You are socially isolated, therefore possibly schizoaffective,” to a prison environment, we would have to conclude that a prisoner placed in isolation is a candidate for the diagnosis schizoaffective disorder,” regardless of demonstrated social interest or social sensitivity, simply because he is socially isolated. 5/ One is reminded of an aphorism of Nietzsche's: “Terrible experiences pose the riddle whether the person who has them is not terrible.”

The psychiatrist's statement “schizoaffective disorder would include your delusions” is manifestly incorrect, and raises a serious concern about the psychiatrist's knowledge of psychiatric nomenclature. A sine qua non of schizoaffective disorder is the existence of an accompanying major mood disorder. As discussed above, if we assume that the patient's delusions--which have been fixed and stable since October 1988--are a product of mania, we must conclude that the patient is now in the seventh year of an uninterrupted major manic episode!

So ridiculous is the psychiatrist's interpretation that one suspects that we are once again confronting the psychiatrist's desperate need to bolster the conclusions of a peer (a member of the social system) no matter how inconsistent with psychiatrist's personal experience with, and current knowledge of, the patient. And again, as is so often the case in the patient's interpersonal relations generally, the patient's identity is held hostage to the psychiatrist's fear of rejection the identity conferred on the patient by a third party, here, the assessing psychiatrist.

Further, the psychiatrist's act of bolstering what is now an obviously inapplicable differential diagnosis offered in the assessment chart (that the patient may suffer from schizoaffective disorder) demonstrates the hypocritical and purely defensive nature 6/ of the psychiatrist's earlier admonition to the patient: “Why are you so concerned with what people say about you? We have talked about this before--that you are too concerned with what people say about you. The assessment was done three years ago; it relates to things that were done three years ago. What is said in the chart has nothing to do with your current treatment. When we started I said we would put the chart aside and give everything a fresh look.”
_____________________

1/ The letter's central concern is inconsistencies in the treatment during the period 1992-1994, and reflects the patient's need to confer order on the contradictory and confusing attributions made about him by others. The patient's concern—a need to harmonize his experiences—became lost, as so often happens with the patient's concerns, in the psychiatrist's defensive response, which masked an internal and unacknowledged struggle over the psychiatrist's own conflicts and prohibitions. See Letter to Dr. Georgopoulos, dated July 17, 1995, discussing the psychiatrist's defensively tangential response to another of the patient's reports.

2/ The psychiatrist is here referring to his comment offered at the August 7, 1995 session in reaction to the patient's request that the therapist prepare a written statement certifying that the patient does not pose a risk of violence, as alleged by his former employer: “It's not important what I (or others) think. All that's important is what you think. All that's important is that you think you are not violent.” See Letter to Dr. Georgopoulos, dated August 8, 1995. The psychiatrist seems to appreciate intuitively some linkage between, on the one hand, statements made by the assessing psychiatrist in the deceptively-benign assessment chart, and, on the other, accusations by peers that the patient is potentially violent, which is uncanny in view of the Letter to Dr. Pitts, dated June 4, 1993 (attached), regarding the possible latent aggressive nature of the misdiagnosis bipolar disorder,

3/ Actually, the psychiatrist has done more than talk about double-binds. He has, on occasion, created them. See Letter to Dr. Georgopoulos, dated August 8, 1995: "Thus, the psychiatrist has created a curious double-bind. In complaining about others' defamatory accusations the patient will tend to face one of two consequences. Either the patient's report that he has been defamed will be interpreted as a paranoid perception or, if the report is accepted as accurate, the patient's reasonable concerns about the defamation will be cited as evidence of the patient's emotional dependency, weakness, and poorly developed sense of self (not merely coincidentally, attributes typically associated with homosexuals).”

4/ See Letter to Dr. Georgopoulos, dated July 26, 1995, n. 2, regarding the psychiatrist's object anxiety.

5/ I suspect that there is something significant and paradigmatic in the psychiatrist's action, in this one instance, of defining a person's intrinsic nature by reference to his manifest status or condition without regard to an examination of the individual's intrinsic qualities.

6/ The psychiatrist's consideration of the diagnosis schizoaffective disorder seems at odds with his attribution to the patient at a prior consultation, “You want to be liked by everybody, you want to be a member of the 'in-group.'” Schizoaffective disorder is typically characterized by a lack of social interest, not an overweening need for social acceptance.

Attachments:

(A.) Letter to Suzanne M. Pitts, M.D., June 4, 1993
(B.) Letter to Suzanne M. Pitts, M.D., June 20, 1994