Monday, March 3, 1997
9 am. First Session with Jerico Freeman. Jerico, who prefers to be called Jerry, made an appointment without referral and came in this morning. Jerry apparently works in the sewers under San Francisco. He's my first patient not affiliated with SII in any way. I found it sort of refreshing to talk to someone who wasn't shuffling bits for a living. Jerry is 41 and a bit rough around the edges. He gives a basic visual impression of being unkempt. He had shaved, but even though it was nine in the morning, he had the beginnings of five o'clock shadow. Of medium height with a powerful build, and curly black hair, Jerry was dressed in a flannel shirt, jeans, and tennis shoes. His manner was furtive. He was constantly glancing at the window, trying to see if someone was there. In fact, Jerry presented symptoms of persecutory delusion. At this point, I don't know enough about Jerry's delusion to classify it as bizarre or non-bizarre. He spoke about a Them--evil apparently, humanoid in appearance, but unable to tell falsehoods. So when he asked and I answered, "One of Whom?" he was satisfied that I wasn't a one of Them. He also describes some non-specific apparently subterranean horror which is massing for an attack of some kind. The suppression of this evil is on the backs of the few (sewer workers?) to deal with. Jerry suffers from intermittent, apparently fibrillary, tremors. Lifting a glass of water to his lips, he spilled virtually the entire contents of the glass, although maintaining the glass in a vertical orientation. Jerry didn't complain of any physical problem, dismissing the tremors as of little consequence. He had no difficulty expressing himself and had normal affect in our conversation. He was concerned about the privacy of our sessions, but in a completely rational fashion. Primarily, he seems interested in enlisting my aid as an ally against the dangers he faces. He is very concerned that others at his workplace will discover he has talked to me, so I must be careful never to call him at work. Apparently, he has a relatively barren social life, although he has a long term relationship with a woman who I assume is a prostitute but whom he calls his "steady hired girlfriend." Finally, in passing, he indicated that he would not be amenable to somatic treatment, because he needed to keep his head clear of the influence of medicines. I presume we'll discover for what he needs to keep his head clear in future sessions.

Friday, March 14, 1997
9 am. Second Session with Jerico Freeman. Jerry is apparently suffering from full fledged persecutory delusions, although without visual hallucinatory features. He believes that he, and a small band of compadres who work in the City sewer system, are battling some form of apparently non-human entities. He believes that these entities, which he has nicknamed CHUDs after a fairly unpleasant movie of the same name, are responsible for the death of Jake, a friend and co-worker. Jake was killed in the Sea Cliff Sewer Collapse in December 1995. He was doing some surveying in the Richmond Transport Tunnel when, according to Jake, he must have stumbled upon a CHUD. Jake believes that there was an explosion, caused by the CHUD, which killed Jake and caused the collapse. The sewer collapse happened before I got to San Francisco, but I still remember the impressive television news footage of that giant Tudor house cartwheeling in seconds into a giant hole and collapsing into a bunch of boards. Jerry is still having intermittent outbreaks of the hand tremors I witnessed during our last session. He told a fairly amusing anecdote of using an unexpected occurrence of the tremors during intercourse to increase his partner's sexual satisfaction. Jerry is still not particularly amenable to somatic treatments and, frankly, I'm somewhat surprised that he came to me for treatment at all. Generally, those with delusional disorders have little insight into their own illness and are reluctant to seek care. An interesting feature of Jerry's case which I haven't resolved is how Jerry believes that a number of coworkers share the same delusions. Perhaps they have been humoring him. A treatment outline for Jerry follows: I must separate out possible physical causes including alcoholism, drug-induced states, dementia, and infectious, metabolic, and endocrine disorders. Then I must separate out other possible mental disorders which might express themselves as delusions, such as mood disorders with psychotic features, schizophrenia, and paranoid personality. But I have noticed no depressive or manic syndrome in Jerry which would tend to rule out psychotic mood disorders, and unlike schizophrenia, there is an absence of prominent hallucinations, incoherence, grossly disorganized behavior, or loss of personality. It's important that I neither condemn nor collude in Jerry's beliefs. Jerry must be assured that the doctor-patient relationship is confidential. Unfortunately, my experience is that delusional disorder doesn't respond particularly well to antipsychotic medication. The medication can reduce the concomitant anxiety and agitation, but does little to stop the underlying delusions. And noncompliance is always a serious issue. I might consider some of the subcutaneous fat soluble forms to assure proper dosage. Most importantly, time and patience is required to gain Jerry's trust and build a relationship. Once we have a good rapport, I will gently challenge Jerry's delusional beliefs and point out how they are interfering with Jerry's normal functioning.

Monday, March 24, 1997
9 am. Third Session with Jerico Freeman. Jerry seemed stressed and tired during this session. He said that he was thinking of calling off our session and calling in sick, even though he doesn't believe that he is suffering from any physical ailment. He just admits to being tired with an aching back. But after a bit of evasion, he told me what is really bothering him--he's having difficulty maintaining an erection during intercourse. Apparently, his mind and attention is wandering. Jerry described having a very active sex life with Diane--an ex-prostitute that Jerry has taken in and is trying to keep from turning tricks. But now he's concerned that inadequate sexual performance will cause her to leave him. I told Jerry that this type of problem is virtually always treatable, unlike an inability to achieve an erection at all, which sometimes has an underlying physical component which can be difficult to treat. Jerry's sexual problem sounds more the result of stress and exhaustion than anything else. I do want Jerry to get to an internist though. Doug Halsey was good, but I have to make sure that he is on Jerry's health plan. Jerry did tell me that he was ordered to seek psychiatric help by his supervisor. Jerry can't say the word "supervisor" without inserting the word "prick" into the same sentence. Jerry isn't one for a submissive attitude towards those with authority.

Friday, April 4, 1997
8:52 am. Telephone Conversation with Diane LNU regarding Jerico Freeman. I had an almost surrealistic conversation with Diane, Jerry's girlfriend. Just as Jerry had started to assume a comforting consistency in my mind, the phone call has revealed that I actually know little about my patient. Diane, who wishes to keep her phone call to me confidential, told me that Jerry had drunk himself into a stupor and wouldn't be coming in for our session. She said that he had achieved some sexual performance success after our last session, but had a setback on Wednesday and ended up drinking so much that he was unable to go to work on Thursday. Then Diane told me that she and Jerry have been living together for six years and dating for another four before that. She's thirty-one now, and met Jerry when, as a construction worker on a college campus, he gave her a wolf-whistle. Far from being the ex-prostitute that Jerry described, she was a college student. Since then, they've been involved in a monogamous relationship. But the revelations didn't stop there. Diane said that Jake, the worker killed in the sewer collapse, wasn't Jerry's friend at all. In fact, Jerry hated him. She intimated that Jake tried to do something to Jerry, but became distracted when Jerry started to awake and had to end our telephone call. In response to my question, Diane told me that Jerry is extremely honest and hates bullshitters, as he puts it. So where does that put us? Diane could be lying about how she met Jerry I suppose. I would assume that a prostitute, in ordinary social commerce, does not admit to her profession. But I didn't get the idea that she was prevaricating. She seemed quite forthright about her past with Jerry and was almost insulted that I didn't know that she and Jerry had been dating as long as they have. Jerry could have lied about both Diane's past and about his relationship with Jake, but only for reasons that I can't fathom. If Jerry was lying to me about Diane's past, is it that he has a need to feel superior to Diane? When they met, she was a student and he was a laborer. Does that prey on his mind? I will have an interesting next session with Jerry, but I must maintain Diane's confidentiality. I'll even treat Jerry's missed appointment as a "no-show" rather than a cancellation.

Thursday, April 10, 1997
Jerico Freeman spoke to the service and asked for an appointment on Monday. He said that he had been out of town on some emergency last week and that is why he missed the session. But if Diane is to be believed, he was really passed out in a drunken stupor. We'll have to explore whether Jerry is, in fact, a pathological liar.

Monday, April 14, 1997
9 am. Fourth Session with Jerico Freeman. I have a problem with Jerry. I have no idea how far to trust what he's telling me. Now I see all sorts of signs of lying, but they could easily be my projection upon him--I'm expecting him to be lying to me. He told a completely unbelievable revenge fantasy about joining with his mother to murder his vicious father in an act of self defense. I believed Jerry when he told me that his father was a son-of-a-bitch, though. There was something about the way that Jerry talked about the canings and the poor treatment of his mother that just rang true. Apparently, his father worked in the penal system, as a guard perhaps? He walked with a cane--a particular bamboo cane with a dragon's head, towards which Jerry has a strong negative association--and used it to beat Jerry and his mother. Jerry certainly does have an extremely negative attitude towards those in authority that an abusive father would help explain. But Jerry is also evasive during our sessions. Anytime I wander into an area which feels unfamiliar to Jerry, he reacts with suspicion. I have the strong feeling that there is much that he is hiding from me.


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