’76 to ’77 he was in an eight-month therapy which he describes as “scream therapy” with Raven McCracken at “Pathways.” He saw Dr. Oliver Tipton in Cambridge for four sessions, the last appointment being four weeks ago. He saw Dr. Olliphant, a psychiatrist, on one occasion. She prescribed Sinequan of which he took 10 mgs. on one occasion.
My initial impression is that this is an agitated depression in a severely obsessional and schizoid young man. There is some question of whether he is decompensating to a psychotic state. There does seem to be some indication of intrusion of more primary process material. However, he appeared more organized (although more depressed) in this appointment than he had appeared on 8/17/81. This patient has had a physical examination with Dr. Cindy Shepard, his blood levels etc. are within normal limits.
My plan at this point is to order an EKG as well as a deximethasone suppression test. I gave the patient a prescription for 1 mg of Decadron to be taken at 11 p.m. on Sunday night and with instructions to have a 4 p.m. cortisol level drawn on Monday.
I discussed the possibility of psychological testing with Dr. Andrew Berl. In his estimation, it would be preferable to postpone psychological testing until after my vacation in early September. The reasons for this are twofold: first, if this is a decompensating process it would be helpful to observe the patient over the next two weeks; second, there is some possibility, although slight, that this psychological testing may make the patient more disorganized. This would be particularly difficult during my absence of the next two weeks. I would order psychological testing upon my return to consider the question of underlying psychotic process, to question issues of sexual identity, to evaluate depressive and suicidal ideation, to evaluate his reality testing, specifically around religious preoccupations, and to evaluate some of his ego strengths.
I have given the patient a prescription for Serax, with dosage instructions. He has taken Valium in the past without difficulty.
I would recommend that when he is seen next week the possibility of changing to an antipsychotic, such as Stelazine, be continued when he can be followed over the course of the week.
I have discussed this case with Dr. Jeffrey Parsnip, who will plan to see the patient on Wednesday at 3 p.m.
August 26, 1981
Jeffrey F. Parsnip, MD/MB
Harvard University Health Services, Psychiatric Clinic
As arranged by Dr. Jennifer R. Hornstein, I met with Mr. Scialabba today. My assessment, which is in agreement with Dr. Hornstein’s, is that this man suffers from a rather severe endogenous depression superimposed on a schizoid personality.
Symptoms of major depression, which have been present for two to four months, include frequent early awakening; constipation; absent interest in sex; diurnal variations, with early morning the worst; compulsive eating; and profoundly decreased energy. I do not think that he suffers from true panic attacks but rather from somatic symptoms of anxiety.
The only family history of emotional illness is a first cousin, mother’s brother’s son, who committed suicide at age 21. There is no family history of alcohol abuse.
Certainly the chronic decline in functioning from his levels of a decade ago is disturbing. After graduating Harvard in 1969 with a group 2 average, he flunked out of Columbia, where he was studying history. Since then, he has spent a number of years working as a social worker in a local welfare department, though he says that this job was largely paperwork. He has been working as a receptionist at Harvard for the last year. He has no close friends and although he has had sexual intercourse he has not had close or enduring relationships.
He describes his mother as having been dominating, although very nervous, and his father as a timid, weak man. Father held an office job and mother worked in a textile factory. There is one brother who is taking night school courses and works in the Massachusetts Public Works Department. Thus, the patient greatly exceeded the level of the success of his family simply by going to Harvard and doing well there.
I wonder whether part of his subsequent decline is attributable to oedipal fears which his success represented. He now has multiple fears of losing control, which he fantasizes would result in his becoming passive, being unable to hold a job, going on welfare or into a hospital, and not being able to take care of himself. This may be a regression prompted by his earlier successes.
He describes having wanted to be a priest from the second or third grade, a role that was highly respected within his community. He currently has fears that his turning away from religion may have been a mistake and that he could be damned to hell for this. He also fears punishment for compulsive masturbation, which he says he is engaged in daily for ten years prior to his loss of sexual urges these last few months.
Given the chronic schizoid adaptation, the apparent decline in function over a ten-year period, and his interest in religion and philosophy, I looked hard for a thought disorder but was unable to satisfy myself of the presence of one. His functioning within the last four months is clearly discontinuous with his chronic level of functioning over the last ten years. During these four months he has had classic signs of an endogenous depression of severe degree, with agitation. In this context, I am rather strongly inclined to see him as having major depression superimposed on a schizoid personality.
Physical examination has been performed and is normal; dexamethasone suppression test is negative.
I believe he will likely benefit from tricyclic antidepressant therapy. I began discussing this with him today and will meet with him for further discussion tomorrow. Will probably start him on desipramine at that time.
September 14, 1981
Jennifer R. Hornstein, MD/MB
Mr. Scialabba’s return appointment today. He has been on desipramine since August 27. States that he is lightheaded when he stands, also still lethargic and sedated. He saw Dr. Wolf before our appointment.
I spoke with Dr. Shepard, who informed me that he was postural. Blood pressure is indicated in the medical record.
Says he had a brief resurgence of energy at the end of August, but since then has had a resumption of his depressive symptoms. Broken sleep; appetite and sexual energy low. No signs of a thought disorder. Feels hopeless and helpless.
Summary of his medication is as follows: 8/27 desipramine 25 mg qhs. On 8/28—50 mg hs. From 8/29 until 8/30, 75 mg qhs. From 8/31 until 9/2, 100 mg qhs. From 9/4 until 9/7, he was on 150 mg desipramine. From 9/8 until 9/13, the dose was decreased 100 mg qhs for symptoms of faintness.
Given the patient’s symptoms of faintness, lightheadedness, and postural hypotension, I have decreased his dose to 75 mg of desipramine. I will keep him on this dose for one week and then consider increasing the dose in slow increments.
I have discussed psychological testing with Maggie Ewing, who will refer him to a psychologist. I have requested that the psychological testing consider these questions: an underlying psychotic process, sexual identity, depressive and suicidal ideation, reality testing (specifically around religious preoccupations), and ego strengths.
The patient has stated that he is considering a referral to the Boston Center for Modern Psychoanalytic Studies. I have informed him that I will give him a referral if he wishes.
September 21, 1981
Jennifer R. Hornstein, MD/MB
Mr. Scialabba in for a return appointment. The medication is relieving his anxiety somewhat, but he continues to feel extremely sedated and exhausted. He has no further complaints or faintness or weakness. Still has some difficulty falling asleep, though not so much, and occasional early morning awakening. I increased his medication to 100 mgs of desipramine.
We discussed his frustration with his slow progress. He talked about his anger, and wondered whether it would be useful to spend the session expressing his anger. It seems he is particularly angry at the psychological evaluators who administered the psychological testing. He talked at great length about feeling insulted by the psychological test and expressed his anger at being dependent on “clerks and stupid bureaucrats.” He associated this with more longstanding anger