LETTER FROM AL.

Patient: A.G. Jr. Referred by: No ref. Insurance: N/A

2/17/96 Patient arrives early, describes symptoms: he's in a high-stress job (though when pressed, patient is vague about the concrete responsibilities of the job). Feels inadequate when compared with his immediate supervisor, who, it seems, is more popular, etc., esp. with the ladies. Has grandiose self-image ("I believe it's my destiny to save the earth") that leads him to make strange cognitive misperceptions ("This afternoon, I made it snow").

Patient talks for one hour straight. Will meet once/week. Prescribe initial course of relaxants.

6/15/96 Patient responding well to feedback therapy and mild relaxants. Seems confident, upbeat, somewhat aggressive. When I suggest taking patient's dosage down, patient becomes quite cutting, accusing me of "trying to take us back to the Stone Age."

Patient seems to have two distinct modes of behavior: sanctimonious/pious/messianic and aggressive/evasive/argumentative.

6/17/96 Patient telephones from his office, demanding $1,000, the "maximum legal individual contribution." When refused, he becomes belligerent. Hard to get the dose exactly right on patient's meds.

7/23/96 Patient talks about the death of his sister, by lung cancer. Recounts in detail her last month. Seems quite upset. Blames tobacco industry for her death. When Dr. points out that patient himself once grew tobacco, lobbied extensively for the industry, and that, in any case, when a girl such as patient's sister begins smoking at 13-as patient admits happened-perhaps in addition to the "tobacco industry" (note to self: explore poss. that patient is schizophrenic/paranoid) patient should blame his parents for allowing her to start at such a young age. Patient continues to sob.

1/21/98-2/4/99 Patient under enormous pressure at work. Immediate supervisor in some sort of grave danger. Put patient on a course of Relaxo 345mg/day and Wellbutin 600mg/day. Patient demands increased meds. When warned that increasing the dosage will leave patient dull, listless, robotic, patient cries, "Exactly!"

10/15/99 Patient resurfaces, upbeat. Expresses exuberance at something called the "Bradley challenge," and smiles tightly when asked to describe it.

Patient still delusional. Claims to have "invented" modern post-Freudian mental-health techniques. When pointed out that this cannot possibly be so-for one thing, patient would have had to do it at the age of seven- patient becomes abusive. Then, strangely, patient claims never to have said what doctor clearly heard him say.

The discussion turns semantic.

12/30/99 Patient obsessed with a "need to win." When asked to define "winning," patient recasts his facial expression into a placid smile and replies, "to help people, to serve my country, to continue the great wave of prosperity that has lifted up this nation." When asked what the consequences of failure are, patient replies that life as we know it will end on the planet. And that a woman's right to choose will be abridged. Doctor cautions patient against messianic attitude. Suggests that "winning" might also be defined as doing one's best in an honorable and truthful way.

Patient accuses doctor of "going negative" and accuses him of misdiagnosing a patient 17 years ago. While it is true that 17 years ago, doctor did indeed have a patient under care who had complicated symptoms that required longer than usual to diagnose, doctor did not "misdiagnose him." Doctor asks if patient has been doing research into doctor's background. Patient responds by accusing doctor of misdiagnosing a patient 17 years ago. Doctor asks if patient believes that distorting the past serves any real purpose. Patient responds by accusing doctor of misdiagnosing a patient 17 years ago. To everything doctor says ("How is the family?" "Would you like a glass of water?"), patient replies by accusing doctor of misdiagnosing a patient 17 years ago. This goes on for the remainder of the session.

1/31/00 Patient unable to make appointment in person. Calls from somewhere in New Hampshire.

Am extremely concerned that the requirements of patient's job are causing fissures in his cognition/reality awareness. Patient friendly, outgoing, no trace of belligerence or aggression.

Must conclude that patient may never achieve state of complete mental health. While he will always be functional, he may never be fully stable. Course of action: reduce meds. Observe closely.