Friday, March 7, 1997
4 pm. First Session with Thomas Darden. Thomas came into my office for his first session. He is 25, about six feet tall, fairly thin, with dark hair cut close in an almost military style. He is clean shaven except for a goatee and he wears round wire rim glasses, John Lennon style. He was casually dressed without much regard for fashion. The expression about looking like an unmade bed comes to mind. I guess he'd be handsome if he worked at it. When Tom talks, he uses a great deal of hand gestures. I sensed that if his hands were manacled, it would destroy the fluency of his speech. Tom clearly has a ready sense of humor, using the technique of "kidding on the square." He started by commenting on my arrangement of chairs as if it was a test to see which one he would sit in. He was concerned whether the contents of the session would go back to his boss at SII, but was relatively easy to place at ease. We started talking about his work. He moved from the sales department because of complaints about Dan Martini, and ended up at the Internal Help Desk because he was promised some advanced engineering training. But his boss who made the promise is now gone and has been replaced by someone who doesn't feel the need to honor the commitment. Tom's real complaint, though, has to do with his lack of social life and his fear of social interaction. Tom told me some of his prior history after he left college in Pennsylvania. He was a journalism major, which made it difficult for him to get a job. Finally he got a position writing obituaries, and quietly lived a desperate life, drinking himself to unconsciousness in a nightly ritual and contemplating suicide. He somehow got involved with a high school girl named Sharon who seemed to truly care about him. Soon after meeting Sharon, Tom abandoned his journalism career, getting a new job at a computer company in Pennsylvania. For a while he described himself as content. The relationship with Sharon ended, probably because Sharon had to go off to college. The computer job led to his current position at SII. I don't know if Tom still has an alcohol problem. Clearly, though, Tom does not have much of a social life in San Francisco. His desire is to schedule our sessions late Friday afternoon. Most people prefer to go out Friday night. But I can sympathize. I don't have much of a social life in San Francisco either after 9 months here. I hope this won't be a case of the blind leading the blind.

Friday, March 14, 1997
4 pm. Second Session with Thomas Darden. Tom described for me some of the issues that stop him from having a social life. He feels that people are going out as part of an elaborate game--to impress each other rather than to have a good time. Tom found himself falling into the same trap. In fact, Tom is worried that he might be creating imaginary situations to have something to tell his co-workers. He gave me an example of having a telephone conversation with a woman who was concerned about him after she had hit his car. He turned the situation into a story about the woman calling him for a date and that he refused. The interesting part of the story was that, after telling the lie to his friends, he began to imagine that the woman had really been interested in him, that she had really been trying to get him to ask her out. He was reshaping his reality to justify the lie he had told. But the example didn't make it sound to me like his lying was an irresistible compulsion. Rather the lie was more in the nature of a fantasy about getting out of a life which is undesirable. Although he works out--to be ready in case a relationship should ever come about--he describes himself as a home body who enjoys solitary activities. In a jumble of justifications, he described how he didn't have anything to offer a woman, and how he didn't even think he wanted a relationship now because it would stifle his freedom to be crude when he wanted to be. But he also admitted that he was lonely. His response to feeling lonely is to binge-drink beer and feel sorry for himself. Tom described his early family life. His father was an outgoing, large and expansive man while his mother was a polite, passive person who Tom describes as a pushover. His father worked in a chemical plant. When Tom was 10, there was an explosion which killed 35 people instantly. But his father held on for several weeks before succumbing and was conscious during some of that time. Tom remembers being dressed up in his Sunday church clothes and visiting his father, who must have been terribly burned and was swaddled with bandages. His father was restricted to hand gestures and was unable to talk. Although his younger brother was able to talk to his father, asking him when he was coming home, Tom's more mature realization of the extent of the injuries made him shy with his father. Tom remembers holding back and not being able to go to his father's bedside, even when his father motioned for him to do so. Tom can't forget a look that his father gave him, which Tom interpreted as his father telling him that he was sorry. The funeral was such an ordeal for Tom's mother that she had a psychotic break. She snapped out of it after a few days at the psychiatric hospital. But Tom vowed never to go to another funeral. After that, the family moved around a lot, his mother getting involved with a succession of different men. She remarried two years later to a man whom Tom describes as a perfect asshole. Tom said that each member of his family had metaphoric neon signs above their heads directing others how to act towards them. Tom's sign said, "Abuse me, won't you?" Tom's brother Alex's sign said, "Ignore me." And Tom's mother's sign said, "Fuck me and leave me." When Tom said that he needed a drink during our session, I started to remonstrate, then Tom warned me not to accuse him of being an alcoholic. My guess is that Tom suffers from avoidant personality disorder. I suspect that he has strong feelings of inadequacy and hypersensitivity to negative evaluation. This has probably been a pattern from early childhood, perhaps because of his inability to live up to his image of his father. Tom is probably unwilling to get involved with someone unless he is certain of being liked. I also imagine that Tom is unusually reluctant to take personal risks or engage in new activities that could prove embarrassing. There is an overlap between avoidant personality disorder and social phobia. I have heard that some psychiatrists have had good success with benzodiazepines, short term, in helping patients reverse previously avoided behavior, and the full range of somatic treatments that are useful for treating social phobias have application here because of the strong overlap.

Friday, March 21, 1997
4 pm. Third Session with Thomas Darden. Tom began the session very agitated and flustered--a "pissy mood" as he put it. His hands were never still, violently punctuating his sentences, and as he sat in the chair, I got a sense of a coiled spring, ready to be released at any second. Tom's feelings are quite close to the surface. With gallows humor, Tom said that he was agitated because of the recent news of the shooting at the fast food restaurant. Tom was disturbed because the news reports all focused on how the neighbors thought the gunmen was a quiet sort--he kept to himself, he was a good neighbor, clean yard, etc. It's true that the media often portrays a picture of the quiet loner as a potential vicious psychopath. And that's what Tom reacted to. He feels that he is treated differently because of his shyness and social phobia--that there is a stigma in this society if one is not caught up in a social whirl. But Tom's agitation on this point was seemingly disproportionate. Sometimes I think he's joking and sometimes it seems that he is really serious. Tom told me a bit about his childhood after his father's death. He became withdrawn in school, his grades dropped, and he started to suffer nocturnal hallucinations of his father returning as a frightening, grinning figure. He was taken to a child psychiatrist who sounds dreadful. Tom was caught up in the early 80s great rush to prescribe Ritalin. It is illustrative that a shy, quiet, withdrawn kid, perhaps remarkable for using his hands in explosive exposition, would be prescribed such a drug. Ritalin is arguably appropriate only for those kids for whom hyperactivity has reached the level of a learning disorder. The Ritalin eliminated the nocturnal hallucinations but they also destroyed Tom's appetite and imagination. At around that time, his mother married his hated stepfather John, and the family moved to Scranton, Pennsylvania. Tom describes everything as tasting like ash. He dropped a lot of weight and was afraid of crowds of unknown kids. He was especially terrified of the lunch hour. Often, he would skip lunch by hiding in the bathroom. When a group of other kids prevailed upon him to sit with them, he would be unable to get up for food or to interact with others until the end of the hour, when he could dissolve into the crowd of kids leaving the cafeteria. For a kid with a developing avoidant personality disorder, the combination of a father's death, Ritalin, the requirement of learning to live with a new family structure and surrogate father, and a move to a new and unfamiliar environment solidified Tom's problems. Tom took Ritalin on and off for two years, until he chose to stop by himself. Tom described an atypical episode at school where he sought revenge on a bully who had singled Tom out for his special attention. Tom used super glue to good effect, causing the bully's pants to rip at the end of a class. Although the bully suspected and accused Tom of being the perpetrator, the teacher refused to credit such an act to shy, quiet, withdrawn Tom. Interestingly, Tom believes that he may have sought his revenge in part as a reaction to the stereotype which exempted him from his teacher's suspicion. That stereotype is precisely the opposite from the quiet loner as psychopath stereotype that Tom railed against in the beginning of the session. In our next session, we are to discuss Tom's stepfather John.

Friday, April 4, 1997
4:00 pm. Fourth Session with Thomas Darden. We spent most of the session talking about Thomas' stepfather for two years when Tom was approximately 12 to 14 years old. John was an ex-military officer who, together with his two older sons Dave and Lynn, practiced both mental and physical abuse on Tom and his brother Alex. John seems like the most petty of tyrants, using his power to humiliate and abase primarily for his own amusement. As all too frequently happens in these cases, Tom's mother ceded authority to John and then emotionally withdrew, closing her eyes to what was happening. John drove Tom and Alex to complex fantasies of murder and revenge. Even today, Tom feels a murderous rage when he remembers the actions of his stepfather. Although Tom doesn't believe that John ever sexually abused Alex or him, he thinks that John might have come close a few times. Tom's anger over his stepfather needs to be defused. And the meaning of John in Tom's life--and in his current interpersonal difficulties--needs to be explored.

Wednesday, April 9, 1997
Received a couple of memos relating to Thomas Darden. Apparently, there was some concern from Tom's boss that Tom was in need of psychiatric counsel prior to Tom's first session with me. While praising Tom's skills, there was concern over his ability to deal with people. He took the problems that he was supposed to be giving assistance on personally and refused to participate in brainstorming sessions within his department. Given Tom's problems with avoidant personality disorder, none of this is surprising of course.

Friday, April 11, 1997
4 pm. Fifth Session with Thomas Darden. Tom came in looking tired. My first guess was that he hadn't been sleeping, but he assured me that he was physically fine. However, he is feeling a strange duality between the anonymity of being unappreciated versus the exposure of being singled out for praise. He said that he wants to bask in the glory and yet hide in the shadows. I think that Tom is challenging himself to peek out from his shell, and I've tried to encourage him. But he feels that somehow he is a negative causal agent for events. He told me a story where a friend pressured him to go to a bar after work. One of his co-workers attempted to initiate a sexual encounter with a married woman in front of her husband. A fistfight ensued, with the husband losing control to such an extent that he assaulted a police officer who was trying to break up the fight. The husband was arrested, and Tom believes that, although he was merely a spectator, it was somehow his fault. He told another story about passing out at a party and awaking to find that he had been decorated with magic markers while he was unconscious. He felt that he had been trying to fit in, and here he was again, being made the outcast. It brought him back to being the new kid in Scranton when he was a young adolescent. I told Tom that he was taking too much personal responsibility for the incidents that occur around him, and that since much of his socializing involves heavy drinking, he should expect unconventional conduct from those impaired by alcohol.

Friday, April 18, 1997
4 pm. Sixth Session with Thomas Darden. Thomas arrived early to our session. He had taken the day off work, but wasn't really sick--just hung-over. It seems that he'd been spending his time thinking about his lost love. Sharon was a sexually precocious 16 year old high school student when they met in 1994. Thomas was, at that time, 22, and somewhat socially awkward. They began a very intense relationship which Thomas now says that he knew was doomed to fall apart when she went to college. Sure enough, even though her college was within easy driving distance from her old house, within a week she wanted to break up. Thomas tried to let her know that he was still interested in having her back in his life, but the always difficult transition from lover to friend failed. Thomas took her love letters, highlighted certain portions, and scrawled "nasty comments" in the margins. She immediately stopped having any contact with him, calling him a psycho. Once he even went out and stood beneath her window for a couple of hours. Now he worries if he was stalking her, a somewhat moot point considering the distance in both miles and years between Thomas and Sharon now. Soon after, Thomas moved to San Francisco. But he still hasn't gotten over his lost love. I gave him advice which I'm afraid he'll dismiss as trivial nonsense, but I told him to get out more and try to put the past behind him.

Friday, April 25, 1997
4 pm. Seventh Session with Thomas Darden. Tom came in and surprised me by calling me "Doctor" for the first time. I think it is a positive sign--a recognition that he is seeking my assistance, that I am in a position to help. Tom's deep-seated unhappiness is more severe than I thought. He masks it with a sort of sardonic wit, which can serve to deflect an appreciation of just how great his underlying pain truly is. Tom is exhibiting a generalized sense of failure, manifested as a complete unhappiness with his current circumstances. He hates his job, his social life, his loss of Sharon--all of it. He has even raised it to a spiritual level: he feels that he doesn't deserve to live, that he's a "waste of human flesh." He has taken the environmentalist argument of the first world's consumption of the majority of the earth's resources personally--since he's not enjoying his privileged life, he shouldn't be entitled to it. He even obliquely references suicide as a possibility, although I didn't think a suicide assessment was warranted at this time. Thomas is also exhibiting more obvious signs of agoraphobia, although of a slight degree. While he yearns for the safety of his apartment, he hates the loneliness that he feels there. He described what a perfect life would be for him, and it sounds like he craves a life of indolence and no responsibilities. He used an episode from Star Trek, which I had seen, as a metaphor for his having made the wrong decisions at fateful moments in his life, ending in what he believes is failure. Tom admitted that he feels more comfortable among his co-workers than a group of strangers. Since I knew that Eliza's concert tonight was heavily promoted at SII, I suggested that Tom go try to make some social contacts there, and gave him one of the tickets she had given me.

Friday, May 2, 1997
4 pm. Eighth Session with Thomas Darden. We explored Thomas' agoraphobia during this session. He has an adverse physical reaction towards confronting unfamiliar people in crowded situations, expressing itself in panic attacks. He reports a nauseated feeling immediately prior to being thrust into a crowded social situation, only partly relieved by being with people he knows. Thomas feels the most panicky when he believes that he will be singled out for attention by the crowd. Thomas' agoraphobia might be related more to social situations than it is to crowds, and might more properly be diagnosed as a specific phobia connected with panic disorder. I'm still not sure if the panicky feeling is triggered by a fear of being embarrassed or whether it is more akin to claustrophobia. In any case, I should be alert to the possibility that Thomas' alcohol abuse may be in part an attempt at self-medication designed to alleviate unpleasant symptoms. A common complication in similar cases is significiant depression, which effects almost 50% of those afflicted. I feel that the best treatment is still gentle encouragement to enter feared situations. However, if that is not producing results, antidepressant medications, especially the tricyclics and the serotonin reuptake inhibitors have been shown to be effective in the treatment of panic and agoraphobia. And I should tell Thomas to eliminate the intake of caffeine, although computer professionals seem to be highly resistant to this advice. Although somewhat irrelevant to Thomas' situation, he told me a story about a woman in his department, Doris Meckle, who was passed over in a promotion in preference to a male employee who was apparently better liked, and she filed a sexual discrimination complaint within the company. The promotion, which had already been handed out to Thomas' friend Rob, is now apparently being reconsidered. If Rob loses his promotion, he has threatened to file a complaint for age discrimination. So it is a duel of the discrimination complaints. The atmosphere in the Help Desk does seem charged.

Friday, May 9, 1997
4 pm. Ninth Session with Thomas Darden. Tom came in to the session today intoxicated and I was unhappy to discover that he had driven himself. He assured me that he drove better when he was drunk. Right. But in vino veritas? Thomas made an interesting discovery about himself: he almost likes the emotional pain that he feels. Like the tooth that is loose in childhood and, even though it hurts to touch, compels us to wiggle it, Thomas is compelled to experience the seducing pain of emotional trauma. He recognizes when the experience is a negative one, and yet he understands the pain and there is something familiar about it to him. It is as if happiness would be foreign to him and he wouldn't know how to assimilate it into his experience. But he knows how emotional trauma unrolls itself in time. He feels more in control when the emotions are negative. He wonders now if he was trying to prolong his pain by allowing Sharon, after the break-up, multiple opportunities to twist the knife. I think that is probably revisionist in retrospect, but I take his point. He describes himself as a junkie of pain, but I think he overstates it, although he does seem to study the nuances of the pain he experiences. There are people who really do require the feeling of emotional scarring, but I don't think Thomas is one of them. His fear of social settings seems to be completely separate from his attraction to negative emotions, although there is an element of control and the lack of it in social situations, that infuses both. He was less reluctant than previously to consider a somatic treatment, so I prescribed him Librium, 5 mg. three times daily, and told him to cut way back on the alcohol. I think that the mild anti-anxiety effect of the benzodiazepines may help Thomas endure social anxiety better. I wouldn't let Tom drive home himself, so I called him a cab.

Friday, May 23, 1997
4 pm. Tenth Session with Thomas Darden. Thomas spoke mostly about his brother Alex's visit last week. Alex lives with Martha and together they have a two year old son named Jordan. But Alex is beset with jealousy. He suspects that Martha is having an affair, and he is continually looking for evidence to prove his suspicions. Alex thinks he got herpes recently from Martha and that's the proof he was looking for. He refused to accept Martha's attempt to explain it as possibly transmitted from a cold sore in her mouth during oral sex. So Alex packed his bags and went to see Thomas. Thomas sees Alex as sort of an alter ego who lives on the bright side, while Thomas explores the pessimistic side of things. But while trying to occupy Alex with activities unrelated to Martha, Thomas ventured out to many tourist locations around San Francisco and seemed to have an easier time of it than previously. It's too early to fully credit the librium--perhaps it was Alex's company--but Thomas told a story about making himself the center of attention at a cafe by doing an almost ventriloquism act with his hamburger, to the disgust of a table of politically correct vegetarians nearby. Thomas said that it seems like he swings from one extreme to the other--from being terrified by the limelight to seeking it out. He said that he can't get the happy medium that most people consider normal. Thomas said that an uncle once told him that Thomas was quiet and antisocial in an attempt to draw attention to himself rather than avoid it. Thomas hasn't rejected the idea that the uncle might have been right, although the anxiety in public doesn't fit with the theory, unless Thomas feels the anxiety because he feels that it is necessary to put on a performance for the public's benefit.

Monday, June 2, 1997
4 pm. Eleventh Session with Thomas Darden. Tom has decided that his main problem is that he can't interact with women with whom he is interested in having a relationship. He ticked off his assets, but he sees the men who are successful in bars as being smug, self-confident, and supremely able. His own attempts at trying to pick up women have been virtually non-existent. He described a situation where a woman was trying to give him an opening, but he choked. And yet, reminiscent of the Woody Allen movie, "Play it Again Sam," when he is not trying to "score" he can converse with women. He said that he is considered a good listener and that women seek him out to complain about their current boyfriends. He even referred to his perceived empathy as a curse--an example of how quiet, non-threatening guys are completely uninteresting romantically to women. It was obvious that Tom considers this a major problem in his life, so we need to work on it strenuously. My own abilities in this area though are somewhat suspect--I've never had a particularly strong ability to strike up a conversation with a woman previously unknown to me where my intent was seduction. With Tom, I think the largest issue is to build up his confidence. He is still drinking while taking the Librium. He said something odd. Right after telling me that he has been taking the two drugs in combination, he said that he believed that the combination was potentially fatal. I need to be concerned that Thomas might become increasingly self-destructive, especially if he stops taking his Librium.

Friday, June 13, 1997
4 pm. Twelfth Session with Thomas Darden. Thomas went back to Pennsylvania for his vacation. He spent a little time with his mother, but it was marred by disagreements regarding religious beliefs. In a nutshell, she is a devout Christian and is trying to influence the faith of her grandson Jordan, who is being raised by Thomas' brother Alex and his wife Martha, both atheists. They don't appreciate her attempts and send back the gifts with a religious purpose that she sends. Thomas sides with Alex, both philosophically and on the issue of his mother's attempt to influence Jordan's religion. So they fought. But the most momentous thing that happened was that Thomas happened to run into Sharon in a grocery store back home. Their meeting went relatively well, except that Sharon is engaged to be married in about three months. Thomas felt in the back of his mind that there was still a chance for him to work it out with her, but her impending marriage has pretty much dashed those hopes. I get the distinct impression that Sharon and Thomas didn't actually have a lot in common, and I told Thomas so. He said that Sharon was his first and only love. I argued that he really hasn't given anyone else a chance. His vacation, sitting isolated in a cabin in the woods by himself is somewhat typical. We ended the session talking about his overriding concern about what people will think of him, that renders him all but mute in social settings. I think that we have to do some work to try to reduce Thomas' sense of self-consciousness.

Friday, June 20, 1997
4 pm. Thirteenth Session with Thomas Darden. Thomas began the session in obviously high spirits. I assumed that he had met someone and turned out not to have been far wrong. It seems that Sharon has reached out to Thomas. She is not sure about how she feels about the man she intends to marry, and she called Thomas and left him a message to contact her. Through e-mail and then the telephone, they hooked up and relived and partially rekindled some of their old passion. But while Thomas is ebullient, I am less than thrilled. Thomas' relationship with Sharon was all about need and making him whole through her regard. But it didn't have any of the hallmarks of a stable, long-term relationship. I think that his relationship with Sharon was actually destructive, and I told him so, although he didn't like hearing it much. Thomas said that he would have killed himself had he experienced several more months of emotional bleakness such as he was suffering prior to his vacation. I think that Thomas is much more resilient and clear headed than that, but I should remember that he is a depressed patient capable of suicide and I should assess the danger whenever his depression seems to be getting the better of him. And, of course, Thomas is going to gobble whatever crumb of a relationship that Sharon is willing to feed him. I should just expect that and then be prepared to pick up the pieces.

Friday, June 27, 1997
4 pm. Fourteenth Session with Thomas Darden. We explored Thomas' feelings about renewing a relationship with Sharon on her terms. Thomas is starting to feel manipulated--he even did an imitation of a marionette. But he recognizes his obsession over her isn't particularly healthy for him. He is afraid of being hurt again by her. We spent most of the session discussing a dream that has had a strong impact on Tom. The dream is divided into two parts--an apartment with no furniture that is unbearably white, and a bedroom bathed in red light, with an impossibly elaborate bed. Sharon appears as a completely immobile and passive person in the white area of the apartment, but when Tom carries her into the bedroom, she suddenly awakes and they have vigorous sex. But Tom doesn't feel that he can completely trust Sharon, even in the midst of intercourse--he describes a feeling of impending doom. While climaxing, Sharon calls out the name of her current fiancé Antoine. The mirror on the ceiling fades to reveal something like an operating room theater, and a chorus of people are there mocking him, mostly representing for Tom how much he cares about how other people perceive him. After sex, Tom feels very close to Sharon and discusses with her his plans for the future. But although she seemingly acquiesces to those plans, she freezes back to her previous immobile state and the room switches from red to white light again. Tom wakes up crying. Tom believes that the red light, which represented intense emotions, also represented the times in his relationship with Sharon which actually worked--the sexual part. The white light, which accompanied his feelings of being helpless and alone, signified the rest of his relationship with Sharon, where he felt that he never had much in common with her. I also found interesting that Thomas realizes that part of his social problem has to do with a lack of trust and with an overemphasis on how other people are going to view him. It's clearly true that he is virtually immobilized through his fear of coming across poorly in the eyes of strangers. Self-consciousness usually is resolved during those years of teenaged angst. Perhaps there was some event in Thomas' adolescent development which didn't allow him to socially progress past that awkward stage.

Friday, July 25, 1997
4 pm. Fifteenth Session with Thomas Darden. Thomas started the session clearly agitated. His comments quickly took a personal turn as he revealed that the reason for his agitation was that he was unhappy that I had prescribed Librium for his condition. I would describe Thomas as being overtly caustic. He started to vilify me for prescribing drugs as a quick fix when he said that I really didn't know anything about him except for what comes up during our sessions together. He even said that he thought that all psychiatrists were scam artists. Obviously, I pulled back from the emotion of what he was saying and simply reminded Tom that therapy was mostly about his helping himself and that he always had the option to either discontinue therapy or seek help from another provider. Finally, he apologized and told me that he had discontinued taking the Librium as of about three weeks ago. Since Librium is a long-acting drug, it's quite possible that Thomas' agitation was caused by some withdrawal symptoms which are typically delayed in onset. Thomas made it quite clear that he was not interested in trying other somatic treatments. Mostly because of the urgings of his co-workers and Sharon, Thomas got himself a kitten. He's afraid, since he doesn't have many feelings for the kitten one way or the other, that he might have robbed the kitten of the benefit of a loving home. I told Thomas that I thought it likely that he would grow attached to the kitten over time. While he was talking about not loving the kitten and taking the kitten away from other opportunities, I got the impression that he was talking metaphorically about human relationships--either wasting someone's time on him or ending up hating the object of his desire. In some ways, it seemed like he was talking about his relationship with Sharon. Regarding Sharon, Thomas said that they were now pen-pals and e-mailing each other about once a week. Sharon, apparently, has solved her wedding jitters and the erotic heat has been sapped from their communications. I urged Thomas to continue his exposure to social settings and I suggested that perhaps he might want to join a writing club that meets in the bookstore that Thomas frequents. He said that he would think about it.

Friday, August 8, 1997
4 pm. Sixteenth Session with Thomas Darden. Thomas' sardonic sense of humor overwhelmed me several times during the session, and I found myself laughing at his turn of phrase even while he was expressing something that was important to him. He even called me on it once, and I had to apologize. We spoke about his kitten which he's adopted for many of the wrong reasons. Apparently, Thomas isn't particularly fond of the kitten and it has taken over Thomas' life to a substantial degree. Although I'm far from an expert, I found myself giving Thomas advice about how to train it. Thomas is a high-risk driver. He's having troubles with his insurance company who wants to raise his rates substantially. But Thomas views his car as an oasis of privacy and uses it to avoid social interaction with other people. Thomas and I argued a bit about whether drive-thru windows in banks and fast food restaurants were a matter of convenience or were instead to cater to a desire for isolation. But Thomas' most substantial issue is that he has won an expense paid trip to the Bahamas for his job performance. This is a social event with a number of the executives of SII. Whereas most would envy the opportunity to join what Thomas characterized as an all-expense-paid "drinkfest", Thomas is very worried about having to interact socially with the people on the trip. He's so terrified of attention, that when he knew that he was going to win the award, he made excuses to avoid the ceremony. Thomas described classic panic symptoms when confronted with being singled-out of a crowd: heart palpitations, profuse sweating, and a feeling of needing to flee--like a cornered animal. Again, Thomas turned to alcohol in an attempt to self-medicate and quickly downed a six-pack of beer, which he doesn't consider a particularly substantial amount of alcohol. The trip is scheduled for sometime in October, which gives us some time to try to work on Thomas' social phobia in anticipation of the trip. I think it would be appropriate to try to do some desensitization exercises to prepare Thomas for the Bahamas.

Monday, August 25, 1997
4 pm. Seventeenth Session with Thomas Darden. I decided to take a risk with Tom and I'm not sure whether it was a failure or not. Tom is paralyzed by the fear that others might not like him, and so his natural loquaciousness is replaced by mute terror when confronted with uncomfortable social circumstances. I thought I would try a desensitization exercise, so I took Tom to a bookstore and urged him to start up a conversation with a woman who he saw there. While she rebuffed him out of hand with a curse, Tom actually was able to muster the courage to address her and say something that was ad-libbed--after noticing her Cosmopolitan magazine, he said that he liked to take the quizzes offered there. I'd like to try to engage Tom in some previsualization exercises prior to his award ceremony in the Bahamas.

Thursday, September 4, 1997
6:30 pm. Telephone Call from Thomas Darden. Tom called me drunk to cancel his session. He made a cryptic, almost suicidal comment at the end of the conversation--something about being a loser, so why didn't I kill him. I'm concerned, of course, but I think it likely that Tom was more drunk than evidencing any genuine suicidal impulse. I tried to call him back, but if he was there, he wasn't answering his phone. I considered contacting the police, but I have no clear basis for taking that action. However, I do think that I should carefully evaluate Tom for depression. He's cynical, funny, and high functioning at his work--not fitting a classic depressive category. But he is tortured inside and, therefore, at risk.

Friday, September 5, 1997
I had a bad dream about Tom Darden. Something about our conversation yesterday--his tone of voice--was disturbing to me. I tried to call him at work today, but he wasn't there. So I tried to call him at home, but there was no answer. I'll try again on Monday.

Friday, September 12, 1997
4 pm. Eighteenth Session with Thomas Darden. Thomas started out with an antisocial fantasy of permanently becoming a telecommuter. He imagines working at home and responding to all help desk inquiries by e-mail. From there, we started to talk about the awards banquet in the Bahamas. I thought it might be helpful to try some desensitization exercises--like those which failed so miserably with George Landau. I must say that these were not much more successful. Thomas was able to perfectly picture his own failure at the awards banquet. He imagined himself sitting alone, nursing some beers, or hiding out in his hotel room. Thomas' answer is to make up a sick mother to get out of attending. People with strong phobias need to have a very slow approach to flooding, and yet they want very fast results. It overlays a layer of anxiety on top of the process, which complicates the therapy. Again, I suggested that Tom consider Librium, especially as he has slipped back into a pattern of heavy drinking in what I think is an effort at self medication. But Thomas bristled at the suggestion. And he seemed to have lost much of his sense of humor during our session today--instead he was more openly hostile. I l believe that Thomas may have an undiagnosed depressive condition which has been overlooked until now because of his sardonic sense of humor.

Friday, September 26, 1997
4 pm. Nineteenth Session with Thomas Darden. I started our sessions by inquiring about the company trip Thomas was supposed to go in the near future. I think it would be good for Tom to overcome his anxieties and go and try to have a good time. He won't, of course, but perhaps he'll realize that there's little to be afraid of in such a situation. But Tom used my opening to slip in the fact that he has been seeing a woman for the past couple of months. Her name is Karina, and they've met over the Internet. Tom is very self-conscious that they met this way, and he told me that Karina instructed him never to tell anyone about it either. Tom believes there is a negative stigma attached by society to relationships that start online. I think he may be right. Karina was the one who approached Tom through a personal description in the AOL's members guide or something. Tom quickly denied still having this AOL account--I think he might believe that there's a stigma attached to that as well--self-respecting technowizs don't access the Internet via AOL or something. It's funny that I'm able to recognize this fact--must be due to a year of dealing with the employees of a large computer company--some of the culture seeps in. What Tom wanted to talk about was his frustration with his own inability to function within a relationship. While Karina made overtures toward romantic involvement at first, their relationship quickly moved toward the platonic. Tom told me that Karina just broke-up with a boyfriend of many years and didn't really wanted to get seriously involved with anyone yet. But Tom prefers to think that Karina's lack of sexual interest in him is purely due to his own inadequacies. He told me that he believes that Karina just uses him for his computer expertise and help that a friend could offer (like helping unpack). He said that she believes him to have only half a brain and no feelings that she could hurt by acting so cold. But from what Tom was telling me, I saw a completely different picture--a woman still emotionally fragile after an unsuccessful relationship searched for a kindred spirit via the Internet. Not wanting to be hurt again, she asked Tom for his friendship but not a romantic involvement. She sought out Tom's company by coming up with excuses to be around him--borrowing the use of his computer, asking for his help with the move, etc. But because of Tom's low self esteem, he views reality through a filter that makes him interpret every event and motivation as due to his personal failings and inadequacies. He told me that he tried to break off his friendship with Karina by writing her a painful e-mail message. But she refused to stop seeing him. Then he got drunk and called her in the middle of the night. He only half remembers that conversation but believes it was bad. Tom is trying very hard to sabotage his own happiness. I advised him to try and call this woman again and to try and restore their friendship. I'm also bothered by the fact that Tom seems to be drinking a lot. He was drunk when he made that stupid phone call to Karina. He was drunk when he called me a few weeks ago. And from what glimpses I have into his life, I think Tom might me getting drunk on very regular basis. I think we need to talk about it again. Perhaps it is going beyond a desire to self-medicate and really reflects an underlying alcoholism problem.

Friday, October 10, 1997
4 pm. Twentieth Session with Thomas Darden. I have a really bad feeling about this session with Tom. He seemed buoyant and full of enthusiasm for this trip at the beginning of the session--more up, in fact, than I'd ever seen him. He had undergone a revelation that had allowed him to conquer his negativity and face the rest of his life with a new sense of acceptance for his own identity--a new perspective on everything. But it was clearly an act for my benefit. When I called him on it, it seemed clear that even he didn't believe what he was saying, although it seemed like he has made undisclosed plans of some sort. When I questioned him on those, he said that there was nothing concrete. I urged him to take everything in small, manageable steps--a suggestion he rejected with a certain derision. Then, just before the end of the session, Tom told me that he greatly admired and envied the clarity of thought and the peacefulness sometimes reported in those who've made the decision to commit suicide. Before I could talk to him further about what he meant, he was gone. I don't really think that Tom is suicidal, but I am concerned that he may have resolved on some form of action without thinking through all the consequences. I hope his trip helps give him some perspective by taking him outside of his current life circumstances.

Friday, April 3, 1998
4 pm. Twenty-First Session with Thomas Darden. I hadn't seen Tom since October of last year, so when he called me to schedule an appointment, I was somewhat surprised. The last I heard was when he was off to the Bahamas filled with a false bravado. He told me now that he mostly spent the time barricaded in his hotel room feigning illness. Socially, Tom is clearly no better now than he was when I last saw him. He sees himself as a pathetic loner with "self-esteem" problems, as he puts it. He still has his sardonic wit which makes him entertaining, but he uses it to mask a great deal of pain. He also seems like he's capable of violence, although I've seen no overt expression. But there's something eating Tom that seems almost horrific. He told me of an angry verbal assault he made on a woman he was trying to get into bed. He told her that he had a better claim to her sexual attentions because he had invested more time in her than had another more successful lover. Not surprisingly, this wasn't a very effective tack. I wouldn't be surprised if his outburst completely frightened this woman away from the idea of having any relationship with Tom, even if only over the Internet. I've always approached Tom's treatment on a functional level by trying to overcome his own sense of inadequacy and social shyness. Perhaps I should treat Tom as more seriously disturbed and attempt to uncover the underlying causation for his condition. But I'm glad to see Tom back in therapy. I have a chance with him to really make a fundamental difference in his life. I think he does have a lot to offer some woman if she can penetrate through the layers of shyness, violence, and jealousy which he's built up as protection. Properly motivated, I feel Tom would give up his abuse of alcohol and the frustration which now expresses itself as barely contained violence.

Friday, April 17, 1998
4 pm. Twenty-Second Session with Thomas Darden. In today's session, we explored Thomas' current relationships, such as they are. He's recognized that Karina was just trying to use him to cause her boyfriend to become jealous. Tom said that it was particularly ironic that he should be used to evoke another's jealousy, because he was the only man in Karina's life lately with whom she hadn't had sex. He said that Karina dangled the prospect of sexual intimacy before him and then withdrew it, knowing that Thomas was hooked. Well, Thomas seems to have successfully unhooked himself at last. I must say that his read on the situation with Karina seemed to be both accurate and astute. One of his confidantes about Karina is Rachel, a very attractive woman who works with him at the SII help desk and whose cubicle is nearby. As Thomas told Rachel about his problems with Karina, he found himself becoming more and more attracted to her. He has fantasies about asking her out, but he's using the fact that she's in his department as an excuse to avoid doing so. Rachel has attracted her share of admirers from others in the company, however. One of them is Scott Collavito, a graphic artist who, through Thomas' eyes, exudes oily charm. Thomas describes him as perfect in every way, and he hates him for it. Thomas became enraged with jealousy as Scott flirted with Rachel over a period of about a month. So Thomas decided to exact revenge by surreptitiously placing a vicious computer virus on Scott's machine which destroyed his hard drive. When Scott called in to the help desk, he got Rachel. Thomas had not made much of a secret of his jealousy towards Scott and Rachel figured out that he must have been responsible. She reacted by ceasing all communication with Thomas. After a few agonizing weeks, Thomas finally confessed both to the virus and to his feelings towards her which he said motivated him. Rachel reacted rather well. She didn't report Thomas to her superiors and, in fact, complemented him on his writing. I've seen very shy patients in the past make sudden breakthroughs when they desire something strongly enough. Perhaps Rachel will encourage Thomas to take some risks in his attempt to earn her affection. I hope that those risks will be more socially acceptable than disabling his supposed rival's computer.

Friday, May 1, 1998
4 pm. Twenty-Third Session with Thomas Darden. Thomas seemed to be making progress. He was able to muster up enough courage to send e-mail to Rachel asking her to lunch. She accepted. They had a lunch during which Thomas felt awkward--he felt that she was able to sense the fact that he was nervous. However, the lunch was a big step forward. Unfortunately, Thomas still harbors a great deal of jealousy and anger towards Scott Collavito, mostly because of his easy manner around Rachel. Thomas' jealous thoughts seem to have turned increasingly violent, and he has indicated that he may act on his feelings. After weighing what he said, I cannot say that I believe that Scott is in imminent danger of bodily harm, but it is a close call--Scott may be in some danger. However, Thomas' pattern is to make malicious statements, and even believe them if he's in a certain mood, but he rarely acts on them. They are like a fantasy. However, if Thomas continues to express his hatred of Scott by threatening violent present action, I'll be forced to take some action to try to prevent harm which may violate Thomas' doctor/patient confidentiality. Despite his paralyzing shyness, Thomas seems close to at least the possibility of a relationship with Rachel. Now, he seems intent on knowingly undermining any hope of winning Rachel's affections. It's like he's scared that it might work out and then not meet his expectations.

Friday, May 15, 1998
4 pm. Twenty-Fourth Session with Thomas Darden. Tom is caught deep in the clutches of self-fulfilling prophecy. He is terrified of going further with Rachel because even if he's momentarily successful with her, she's bound to rip his heart out as soon as she discovers what a terrible person he is. That fear paralyzes him so that he stands at the sidelines and bubbles with jealousy when Scott, his hated rival, oozes self confidence as he chats with Rachel. Thomas began the session with what turned out to be an elaborately detailed violent fantasy where Thomas vanquished Scott in an unprovoked fist fight. He told it as if it had really happened, and I sat stunned, trying to determine how to get Thomas involuntarily committed. Fortunately, it was just a fantasy. Thomas explained that he felt especially jealous of Scott because of his "type." Thomas believes that everything comes easily to Scott. He described it as Scott possessing a "get through life free" card. Thomas contrasts Scott's easy victories with his own lesser conquests that are the result of such hard fought struggle. To hear Thomas describe it, it's an injustice which is being perpetrated upon him. I tried to convince Thomas that, by asking Rachel out for lunch, he had made a breakthrough. He had taken a risk despite being afraid. Thomas isn't buying it. He told me that he's been invited to a wedding of co-worker and that Rachel is going to be there. Thomas isn't looking forward to it--his last wedding was a less than stellar social showing. But although I'm certain that Tom will be nervous, I'm happy that he's at a social event with Rachel. Perhaps something good will come out of it.

Friday, May 29, 1998
4 pm. Twenty-Fifth Session with Thomas Darden. Tom went to the wedding reception for his co-worker Gina. He sat in the parking lot for 45 minutes and finally mustered up the courage to go inside. He conquered his social paralysis through a combination of self-loathing and the promise of free alcohol inside. He gulped a few beers and then saw Rachel arrive with a date. He was in agony. He's convinced that she brought the guy there as a talisman against him. Soon after, Jennifer and her husband Frank arrived at the wedding, so Tom glued himself to them. There was a girl there whom Tom was attracted to, and apparently she was interested in him as well. But despite a variety of social subterfuges, Tom was unable to steel himself to talk to her. Tom spoke at length about the envy he felt for his cousin Lance, who's apparently particularly gifted at getting women to sleep with him. Tom described Lance's sexual exploits as legendary and repeated some of Lance's boastings about orgies, and sex with twins, and other feats of sexual legerdemain. Half-seriously, Tom suggested to Lance that they write a book together, "How to Get Laid." While Lance's sexual excesses look pretty good from Tom's famished perspective, Tom realizes that's not what he really wants. Tom said that he wants a girl to be his lover and his best friend. Tom is looking for a committed relationship, although I think he'd settle for less at the moment. But Tom wants to learn from Lance how to get women to want him. His perception is that currently women are scared of him. I told Tom that we needed to work on his self confidence, self image and social skills in general and that romantic skills would come as well. As long as Tom feels that he isn't worth a girl's attention, he won't be.

Friday, June 12, 1998
4 pm. Twenty-Sixth Session with Thomas Darden. I think we made some genuine progress today. Thomas began to express dissatisfaction with the course of his therapy, and I was able to use that as an opening to start encouraging Tom to become a more active participant. I told Tom my theory that he is jealous more of Rachel than of the men who pursue her. From his comments last week about the sexual exploits of his cousin, I realized that he didn't envy the actual sexual adventures--Tom's sexual taste tends towards romantic intimacy rather than simply fulfilling carnal desire. But he envied his cousin's ease and the facile way that he was able to approach women in a variety of social situations. Tom envies those who don't have his difficulty interacting socially. I took it one step further, and suggested that Tom may be afraid of succeeding socially--a varient on his fear of failure. A success could put additional pressure on his next attempt, making an ultimate failure much more psychologically difficult to manage. So even when he knows he'll succeed, he is fearful. I told Tom that he was too focused on what others were doing and not focused on his own behavior. Tom did open up to me somewhat and told me something about his own somewhat obsessive personal conduct, including excessive alcohol consumption and masturbation. Tom was embarrassed both about masturbating at all and about what he regarded as his excessive frequency--about five times a week. I didn't tell Tom that for a man living alone, five times a week was fairly moderate masturbatory conduct. With some emotion, Tom recounted a heart-breaking psychology experiment he read about in college. He talked about the work of the Harlows' done in the sixties in the importance of parental affection in non-adult primates. I remember being very affected myself by reading the details of the experiment in which some infant monkeys clung to cloth-wrapped wire dummies as maternal surrogates while others clung to wire dummies denuded of all covering. The Harlows traced the subsequent development of the monkeys which revealed that infants who had not been the recipients of maternal affection grew up to be inadequate as parents. Tom said that he burst into tears when he read about the experiment in college. Tom's soft core is wrapped in the barbed wire of his acerbic wit, but he is really quite a romantic at heart. Perhaps Tom would be better suited to the leisurely paced courtship of a more chivalrous age than to the body-rubbing mock intimacy of a modern dance club or singles' bar. Beyond his social phobia, Tom is beginning to exhibit symptoms of classic depression. I am beginning to think that I should attempt to treat Tom with antidepressants. I know that he spurned somatic treatment after spotty compliance with my attempts to give him Librium last year, but it's worth a try to bring it up again. Not only is he skittish, but I have to be careful in prescribing medication for Tom. I need to skirt a harmful interaction with all the alcohol he drinks, and I need to avoid any medication which is susceptible to overdose--I do believe that Tom is impulsive and possibly self-destructive under adverse circumstances. I asked Tom to create a social pyramid, with easy social goals at the bottom and progressively more difficult goals higher up. Perhaps we can attack Tom's problems utilizing a two-pronged approach of behavior modification and somatic treatment. I think it's time to enter a more active phase of treatment for Tom.

Monday, June 29, 1998
2 pm. Twenty-Seventh Session with Thomas Darden. Thomas brought in his pyramid of social fears which graphically presented a series of increasingly difficult social tasks. At the highest level of difficulty are flirting while expressing sexual interest and attending a party. At a medium level of difficulty is asking Rachel on a date, initiating a conversation with a stranger in a bar, and picking up a prostitute. At the lowest level of difficulty (but still difficult) is asking Rachel for lunch, going to a bar alone, test driving a car, and accepting an invitation to a party. I was surprised that seeking the services of a prostitute inspired less social fear than attending a party. And it was surprising that Thomas had difficulty going into a bar--somehow I thought that he was a denizen of such establishments. Rachel featured prominently on the list: Thomas is still driven to try to win her. In the beginning, Tom spoke of Rachel as a person. He told me all her good qualities and why she was worthy of his attentions. Now, he seems to see Rachel as a prize alone, a goal rather than a person, something that he can rub in the face of Scott Collavito. It's also interesting to me that the initial contacts are so much more difficult for Tom than the continuing interaction. For example, Tom views asking Rachel for lunch as much more difficult than actually going to lunch with her. Since Tom sees the interaction itself as easier than putting himself forward in a manner which could lead to rejection, Tom should probably try to just be a casual friend to Rachel first, diffusing some of the tension between them. But Tom has a way of sabotaging himself. We talked about standing up to salespeople despite the guilt that they often try to inspire. I decided to prescribe fluoxetine for Tom and began a six week trial of 20 mg. q.d., even over Tom's expressed distaste for somatic treatment last year when I had him on Librium for a few months. I asked him to slow down on his alcohol consumption while he was taking the fluoxetine.

Thursday, July 16, 1998
10 am. Second Session with Nina Alvidrez respecting Thomas Darden. Nina is very shy and withdrawn. She apparently suffers from an acute sense of personal inferiority. [...] She is frozen by social situations which involve initial contact with people unknown to her. Actually, in many ways, her avoidant personality disorder is similar to Thomas Darden's, although Nina additionally suffers from a terrible self-image and poor self-esteem. While Thomas masks his self-loathing in caustic wit, Nina has no such shielding. Her poor opinion of herself is quickly voiced to any who will hear her.

Monday, July 20, 1998
2 pm. Twenty-Eighth Session with Thomas Darden. Tom has made some substantial changes to his physical appearance in an effort to look younger. He has replaced his glasses with contact lens, dyed his hair, and shaved his goatee. It seems that Tom is trying to galvanize himself into social action--perhaps an effort to scale his "pyramid of goals" that he showed me during our last session. Tom is about three weeks into his fluoxetine trial, and he described some initial side effects, including a sense of tiredness, mild nausea, and some loss of appetite. However, he feels that all the side effects are diminishing and I'm hoping that trend will continue; I did not adjust his dosage. Another effect that he ascribes to the fluoxetine is a tendency to dream more vividly. He clearly was affected by a particular dream he had a few nights before, so we spent most of the session talking about it. Tom dreamt that he was engaged in painting a room. He heard a voice which, on exploration, turned out to belong to a sexy female creature whose bottom half was human but whose top half was the torso and head of Tom's pet cat. The cat woman gave Tom permission to fly. Tom swooped through the city, flying about with happiness and confidence. Then he decided to use his newfound flying ability to impress Rachel. When he went to her apartment, he found a number of men there in various stages of undress. He also saw Rachel, in her underwear, with semen on her face and stomach. In the dream, the semen was physical evidence of Rachel's simultaneous sexual engagement with all the men Tom found in her apartment. Rachel was completely nonchalant about Tom's discovery of her prodigious sexual activity. When Tom told Rachel of his ability to fly, she wanted immediate proof. She took him up to the roof of the building and, while he hesitated due to second thoughts about his ability, she pushed him off the roof. He crashed to the ground only to be revived by an act of anonymous fellatio which, although he fantasized that it was Rachel, turned out to be performed by the polymorph cat woman. He then awoke. Tom was looking for an interpretation of his dream, but I demurred. I told Tom that what's important about the dream is the feelings that it invokes in him. Of course, I thought it very interesting that he turned a flying dream--generally the most positive of dreams--into an anxiety dream about sexual rejection, inadequacy, the gross infidelity of his love object, and his ultimate demise by her hand.

Wednesday, July 29, 1998
2 pm. Initial Session with Kelly Wiseling respecting Thomas Darden. Kelly told me about an abusive incident which precipitated her seeking my help. Scott Colavito, Thomas Darden's nemesis with Rachel, apparently made some sexually offensive comments to another about Kelly, out of her earshot but within sight. Kelly has the ability to read lips at a distance and she saw what he said. Scott was mimicking what he imagined Kelly, as a deaf woman, would sound like while engaged in sexual intercourse. Kelly angrily confronted Scott immediately and, instead of backing off, Scott pushed further. He later apologized when ordered to by his superior, but Kelly believed his apology was insincere. She hated herself for being reduced to tears later while sitting in the lavatory. Thomas Darden came by after the incident and offered his sympathy, which was appreciated. Tom, indicating Scott, made monkey gestures, so Kelly taught Tom and some of the other programmers the American Sign Language sign for "asshole." Now, when Scott walks by, the group of them all sign "asshole" when he's not looking.

Monday, August 3, 1998
10 am. Twenty-Ninth Session with Thomas Darden. Tom arrived clearly showing the results of a bender that he went on during the weekend. He was disheveled and ragged. He had clearly slept in his clothes. When Thomas first walked into my office in March of last year, he thought his choice of which chair to sit on was a test: "Which chair marks me as a psycho?" It's ironic that now I note that Thomas picked the couch for the first time, and it worries me. His whole attitude seemed to suggest someone who'd given up. He seems to have allowed himself to succumb to his loneliness and to have forsaken his recent struggle for social achievements. He told me that he sees himself mirrored in the faces of the wasted old men who sit at the lunch counter of a faded coffeeshop. And he feels a strong connection with the suicidal character portrayed by Nicholas Cage in "Leaving Las Vegas." I'm concerned that Thomas may be leaning back towards suicidal ideation. The upshot of all this is that I don't believe that the fluoxetine trial has been successful, either because it is the wrong drug or because of problems in patient compliance. We began the fluoxetine on 6/29/98 for a six week trial. If I'm not seeing positive benefits by our next session together, I'd like to switch to another serotonin reuptake inhibitor altogether, perhaps Zoloft, rather than increasing the dosage of the fluoxetine.

Monday, August 17, 1998
12 pm. Thirtieth Session with Thomas Darden. I had a very disturbing session with Thomas Darden today. He surprised me by describing a set of non specific, non persecutory auditory hallucinations. These hallucinations have apparently been going on for some time, although they have gotten stronger since Tom began the Prozac. I went through the literature and was unable to find any specific references to Prozac-induced hallucinations. Furthermore, Tom reports that these hallucinations are long-standing, although perhaps they didn't previously have the same frequency or intensity as they have now while Tom is taking Prozac. The auditory hallucinations are causally linked to nightmares, although they are not related to the subject matter of the dreams. The nightmares all end with a terrifying moment that seems mostly inspired by some trivial event in the dream. The terrifying moment ends in a burst of adrenaline. He feels pressure at the base of his skull, a tingling down his neck, and then he begins to hear an unintelligible jumble of voices, all strung together, all speaking rapidly and urgently. Tom is captivated by that part. He believes that he's somehow broken through a form of dimensional rift and has made contact with beings from somewhere else. Tom said that he can sometimes reproduce the adrenaline rush portion of the nightmares even while awake, although he can't summon the voices. Tom also described some other recent disorientations which he believes are caused by Prozac. These include dizziness and feeling faint. Given the above, I decided to discontinue the Prozac trial. Obviously, in light of the psychotic nature of the auditory hallucination, I first thought of insidious-onset prodromal schizophrenia, or a schizophreniform disorder. Schizophrenia is characterized by both negative and positive symptoms. While the auditory hallucinations can be a marker, I didn't think Tom exhibited signs of the other positive symptoms which, broadly, are delusions, bizarre behavior, and positive formal thought disorder. Unless I stretch Tom's asociality, he doesn't seem to possess the negative symptoms--affective flattening, alogia, avolition-apathy, anhedonia-asociality, attention. Furthermore, I've always considered schizophrenia to be a diagnosis of exclusion, especially in light of the relative severity and limited scope of the treatment options. There's no evidence to tie these events to a bipolar condition, and I haven't noticed bipolar tendencies in Tom. I'd like Tom to undergo a thorough physical to rule out temporal lobe epilepsy particularly, but also tumor, stroke or other brain injury; endocrine or metabolic disorders (especially porphyria exacerbated by chronic alcoholism); or drug abuse or the effects of alcohol withdrawal. I am not prepared to make a diagnosis, although I'm leaning towards the conclusion that Tom is suffering from an atypical case of unspecified delusional disorder. Delusional disorders require that the delusion is non-bizarre although false (the delusion that one is being deceived by a lover is common). Tom's belief that the voices come from another dimension would usually be considered bizarre. But Tom is trying to explain the source of voices which clearly don't have a terrestrial source. His attempt to explain them through science fiction rather than resorting to radio transmitters planted in his head or thought control exercised by another seems almost reasonable under the circumstances. Otherwise, except for his social awkwardness, Tom is high functioning and not markedly impaired and he has none of the disorganized speech or behavior or other negative symptoms of schizophrenia. However, since Tom reported that the Prozac had increased the frequency and intensity of the delusion, I want to make sure that this isn't a side effect of Tom's tendency to mix Prozac with substantial alcohol consumption. So I asked Tom to discontinue the Prozac and wait a week and then begin a six week trial of Zoloft, 20 mg. q.d. upon awakening.

Wednesday, August 19, 1998
2 pm. Fourth Session with Kelly Wiseling respecting Thomas Darden. Kelly told me that she has a crush on Thomas Darden. The irony is that she's too afraid of rejection to make the first move. I'm in a tricky situation because I can't really push Kelly to begin an involvement with Tom and I can't really push Tom to begin an involvement with Kelly.

Monday, September 14, 1998
12 pm. Thirty-First Session with Thomas Darden. Thomas quoted the old aphorism today: "When it rains, it pours." Sharon unexpectedly moved to San Francisco to join the nursing program at UCSF. She contacted Thomas and they had an evening together, which ended up with them having sex. While Thomas believes that each was only looking for a one night stand, Thomas admitted he felt a rush of old emotions towards her. I'm obviously not surprised and I'm a bit concerned he's going to renew a relationship that was quite destructive. Thomas also said Rachel invited him out to lunch. Thomas thought this was the opening he had sought, until Rachel showed up with Kelly Wiseling. Rachel was obviously trying to set up the two of them together, which dashed Thomas' hopes as far as Rachel went. But Thomas liked Kelly, although he said he can't see himself with her. I'm undecided if Thomas' hesitation is related to Kelly's deafness. He says it isn't, and he even appeared to try the handicap on for size--he declared he'd rather be deaf than blind or unable to taste, smell or feel. Thomas said he thinks Kelly is too good for him--as though she's out of his league. But perhaps he's just covering his uneasiness about dating a deaf woman. Thomas reports he hasn't had any side effects from the Zoloft, although he did say he had a bit of trouble initiating an erection the other night when he was with Sharon. However, he also said he had a considerable amount to drink that night, not to mention the long and emotional history the two of them share together.

Monday, September 28, 1998
12 pm. Thirty-Second Session with Thomas Darden. I'm seriously considering involuntary commitment for Thomas. Although I have concluded that he's not an imminent suicide risk, I am concerned for his long term safety. Thomas is filled with suicidal ideation. He told me in detail about watching a moment which had been captured on television of a man committing public suicide by shooting himself in the head. He considers suicide as an end, rather than a solution to anything. But he also feels that an end would provide relief from the pain of his loneliness. This latest crisis was triggered, ironically, by one of the bravest things that I've seen Tom do. He replied to a video dating service mailing and even went for an interview. There he sat down with a saleswoman and told her what he was looking for in a mate. She responded with a hard sell at a high price point. When Thomas indicated that he wasn't interested in spending that much currently, she asked him if he wanted to be alone for Christmas and wasn't he willing to spend a little to find the love of his life? Thomas felt ill-used and left, disgusted with the process. I questioned Thomas about why he took this step now, since during our last session he felt overwhelmed with romantic possibilities. But he said he just saw Rachel, Sharon, and Kelly as opportunities for heart-break--the anonymous women who are theoretically matched with his interests by a video dating club seemed an emotionally safer choice.

Wednesday, September 30, 1998
2 pm. Seventh Session with Kelly Wiseling respecting Thomas Darden. Kelly really liked Thomas Darden and she is disappointed that he hasn't followed up on her obvious interest. I couldn't very well tell her that he's suffering from a phobia against societal interactions that's so overpowering that he's actually suicidal. [...] Actually, Kelly seemed quite willing to take positive steps to end her loneliness. She's even willing to suffer the possibility of further rejection and continue to give Thomas a chance.

Monday, October 12, 1998
12 pm. Thirty-Third Session with Thomas Darden. Tom began our session talking about the seductive allure that the Golden Gate Bridge has as a method to commit suicide. But he really seemed better today and I was less concerned that Thomas was an imminent suicide risk than I was last week. Thomas said that he hasn't really been thinking about suicide very much recently. He told me that he likes to watch sunsets and was quite poetic describing almost a hopeful future that he conjures up as he watches the setting sun. We explored Tom's high school years today, and I can see that many of Tom's social functioning difficulties can be traced back to those days, and probably before. Apparently, Tom was sought after by girls even though he refused to take any initiative. But Tom always rejected their advances. He told one particularly painful story about a girl named Jennifer who declared her romantic feelings towards Tom and who was then crushed when Tom publicly and literally tossed those feelings aside. Tom thinks back on this particular incident and almost feels nauseous with a combination of regret and lost opportunities. I told Tom that I wanted to explore his high school and college years in more detail during our next session together.

Monday, November 2, 1998
12 pm. Thirty-Fourth Session with Thomas Darden. Thomas told me that he has been absorbed by the uneventful routine of work, which has helped him get his mind off his problems. I also think that I've noticed an improvement ascribable to the Zoloft, which I've increased by 10 mg. I'm convinced that the roots of Tom's avoidant behavior can be traced to early sexual exploration. We talked about college today, but it was clear that he already was having problems functioning in a social environment at that time. I'd like to explore further back, before high school, to see if there's one stand-out traumatic event from his childhood. Thomas told me of his loneliness and homesickness when he first went to live in the dorms as a freshman at Penn State. He had a roommate, also named Tom, who had a girlfriend Leah, who was a fantasy object for Tom Darden. Tom recalled an event, which deeply shamed him, where Leah caught him masturbating. The next day, Leah and her boyfriend had sex while Tom watched and masturbated. This was Tom's first sexual experience with another person. While engaged in sex with the other Tom, Leah even pressed Tom to admit that he wanted her to orally copulate him. Although he made the request, she did not comply, although Tom's presence seemed to excite the copulating pair. Tom later told both of them, individually, that he had been made uncomfortable by the event, and it was not repeated. Tom said that their friendship was strained thereafter. Apparently, Tom was--and perhaps still is--disconcerted by a feeling that he might have latent homosexual tendencies. It sounds like he might have had some homoerotic fantasies which have terrified him into a false belief that he might be a closeted homosexual. I think it's pretty clear that he is not. Perhaps I should try to reassure him on that point.

Monday, November 16, 1998
12 pm. Thirty-Fifth Session with Thomas Darden. I had intended to use this session as an opportunity to delve back into Tom's past, especially the time he spent with his abusive stepfather. I have a hunch that the bulk of Tom's troubles spring from those days. However, Tom came in today in particularly good spirits. He sought a job transfer and got it. He's going to be working in the technical writing department on SIIMole documentation. Tom surprised me by showing a marked lack of interest in Rachel and a renewal in interest in Kelly Wiseling. He genuinely seems to like her--and of course she has a strong interest in him. He chided me for referring to her as a deaf girl--as if that's her most outstanding quality. He seems to have developed a genuine friendship with her. He said that her deafness intimidated him at first, but now he hardly notices it. He's working up his courage to ask her out, but he can't right now because he has renewed a sexual relationship with Sharon; they see each other now about once a week. Tom describes the sex as more than satisfactory, and although he says that he isn't seeking a deeper emotional commitment from her, he sometimes lets himself slip into pretending that one exists. I chided him about his slipshod attempt at practicing safe sex, but more than STDs, I'm concerned about the emotional damage Sharon could easily cause Tom. I'm hoping that he can use the sexual fulfillment that Sharon offers to make himself less sexually desperate and more able to relate to Kelly on an interpersonal level. Perhaps they'll be able to make each other happy. Tom also admits that the Zoloft has been helping him. He's noticed a change himself.

Monday, February 15, 1999
12 pm. Thirty-Sixth Session with Thomas Darden. This session didn't go well. Tom came in extremely happy. He told me that he had proposed marriage to Sharon and she accepted. He wanted my congratulations but what I had to give was more cautionary. He wasn't interested in hearing that and became extremely hostile towards me and towards the work we've been doing together. He's come to the conclusion that I'm the problem, and he indicated that our sessions together were at an end. I suspect they really may be. Tom is likely to go through with his marriage to Sharon--it will probably increase his short term happiness--and my reservations about his relationship with her will be antithetical to his continuing commitment to her. Perhaps I'll see him again if the relationship doesn't work out, but even then, I probably won't. He'll assume that I'd gloat. Unfortunately, Tom fell into his relationship with Sharon when he was much younger, and his inability to interact socially has forced him to view her as his only option. Tom had been obsessed with the physicality of his relationship with her, to the point of stalking her after they broke up. But he told me that they shared little else other than their sexual appetites. While I have reservations about whether his relationship with Sharon is healthy, I am glad that Tom will not be living alone. I was concerned about Tom as a suicide risk and he was certainly prone to wallowing in his solitude, becoming increasingly self-destructive especially with alcohol. Sharon is likely to ameliorate those effects considerably. I'll have to remember to send the couple a wedding present.


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