EFTA01076507

Name: 
Date: November 17, 2009 
Mr. Epstein never threatened her. There was no issue of her being held against her will, kidnapped, 
specifically threatened, or physically or mentally coerced, other than has noted above. She reports that 
she understood that she was to lie about her age, take off some of her clothing, and give a massage to 
an adult male and that she did so because she wished to be compensated $200 for that service. She 
reports that she did not know that other girls had been touched until after she left the Epstein residence 
and that she was apprehensive and fearful during the time she was with Mr. Epstein, but was able to 
tell him no and to step away from him. 
2. Demographics. 
saw Mr. Epstein on one occasion at age 16 as previously noted. Her 
parents divorced when she was four years of age and her mother subsequently remarried. She comes 
from a middle class socioeconomic environment. Her stepfather managed a Home Depot store, where 
her mother also worked. Problems ensued when the children of the respective parents merged into a 
single-family unit. Her mother and stepfather dated for eight years and married when she was 11. 
There were seven children in the household — her two brothers, 
and 
; herself; three 
stepbrothers,_, 
and-; 
and a half-sister from her mother's previous marriage. 
was a B student in school and reports that she believes she had attention deficit disorder as 
a child. She graduated from high school with a 2.9 GPA. 
She began dating at age 15. She reports that she had five significant relationships, but was sexually 
hyperactive (a "sexual extravaganza") from ages 17 through 19. She dated boys who were abusing 
marijuana and alcohol al, 
-Alt.
 Her second boyfriend, 
, who was two years older, 
was arrested for breaking and entering, vandalizing buildings, and abused marijuana. At age 19, she 
became pregnant by her boyfriend 
and aborted that child. She reports she currently has an 
excellent relationship with her boyfriend". 
She lost her virginity at age 15, prior to seeing Mr. Epstein. She reports it was a memorable and good 
experience. She notes that since that time she has had approximately 35 sexual partners. She had one 
experience when she intimately kissed another woman at age 18, but sees herself as heterosexual in 
orientation. She reports that she has been involved in group sexual encounters with her friends, had 
61 
EFTA01076567

Name: 
Date: November 17, 2009 
anal sex at age 18, and has given and received oral sex beginning at age 15 or 16 (prior to her contact 
with Mr. Epstein). She has used various marital aids, self-stimulates, has had digital anal contact with 
her boyfriend., has used chocolate body paint at age 18, and enjoyed dressing up in provocative 
outfits at age 18. 
She notes that she went "sex crazy" in the 11th grade and felt that she "needed to be with guys." She 
notes that she was sexually active because she felt it would hold men in relationships. Friends told her 
she was developing a bad reputation and she thought she was "losing" herself with drinking and sex. 
She felt ashamed of her sexual activity, but did not curtail it. She notes that her mother supported her 
decision to abort the pregnancy and she notes she did not feel ready to care for another human being at 
that time. III, 
the father of the child, was not interested in her having a child. 
One of her best friends, 
died in an automobile accident at age 20. Her death had a 
significant impact on-. 
She still becomes tearful when discussing it. She lost another close 
friend, In 
in an automobile accident when 
was 18. She suffered another loss when one 
of her previous boyfriends, MUM 
was murdered at a party. (She reported no significant 
losses to Dr. Kliman.) 
She received three speeding tickets for going at least 15 mph over the limit and was ticketed for 
underage drinking while living in M. 
She began using alcohol at age 17 and would consume 
eight shots and a couple of beers at a single sitting. She developed tolerance, had two blackouts, 
would drink to the point of vomiting, and she reports for a two-year period (during her junior and 
senior years of high school), she drank to the point of intoxication and vomiting once weekly. During 
her senior year, she was "out every night looking for a party in order to get drunk" She reports that 
she felt guilty about her drinking and attempted to reduce the amount that she drank. 
She began using marijuana while in the 1 I th grade, age 17, and developed tolerance to the drug. Her 
largest daily consumption represented $45 a day. When intoxicated with marijuana, she reports her 
memory was impaired and she would forget conversations. She felt that the marijuana affected her 
memory adversely. She used cocaine at age 21, using on five occasions. She used LSD on three 
62 
EFTA01076568

Name: 
Date: November 17, 2009 
occasions at age 19 and reports she had good trips. She also used hallucinogenic mushrooms. Fier 
brother would hunt and find mushrooms and she arranged for him to sell them to people she knew. 
She also used nitrous oxide obtained from whippet inhalants and bought Xanax and Percocet on the 
street. She obtained Adderall without prescription approximately 10 times and felt euphoric when 
taking amphetamines. She would attend parties and participate in drinkinggames and reports that she 
hung out with a "red neck crowd," where there were frequent fights. After the patties, she would often 
have sex with participants in either their home or their car. She reports that she frequented a bad area 
of town and felt that she needed to carry a baseball bat under the front seat of her truck to defend 
herself. 
reports that she has always had problems with attention, concentration, persistence, and 
pacing herself and that she is easily sidetracked. She has difficulty making decisions and reports that 
she always has. She has difficulty planning, difficulty with task completion, and reports that she 
frequently gets angry and has episodes of road rage. All these symptoms, except the road rage, 
preceded her contact with Mr. Epstein. She reports she felt she had ADD since she was young. 
Treatment notes show OCD symptoms, which she reports started when she was in middle school, she 
believes. She notes that if things "weren't perfect," she would "freak out." The symptoms began after 
she had a myringotomy and tubes placed in her ears. The OCD required her to have everything in its 
place and she would become angry or upset if things were moved or disturbed. In addition, she would 
have to repetitively count and if interrupted, she could not go on with other conversations until 
completing a ritual. These symptoms preceded her contact with Mr. Epstein. 
She made a suicide attempt by overdose with hydrocodone and, on another occasion, she was admitted 
to a psychiatric hospital in Tennessee with statements that were construed as suicidal. "I wish I could 
die." She was held overnight. She believes she was 19 at the time. On another occasion, she reports 
she cut her arm with a knife because she wanted to "feel pain." Bipolar symptoms of euphoria were 
only associated with the use of Adderall and lasted only for the duration that the medication was 
usually effective. Her periods of racing thoughts were attributed to episodes of anxiety. 
63 
EFTA01076569

Name: 
Date: November 17, 2009 
While 
reports no other episodes of sexual trauma other titan that which occurred with Mr. 
Epstein, records 
records) show that there were other sexual concerns. At 
age 18, she notes while in therapy "she has to keep her bedroom door locked or her older stepbrother 
...tries to do `sexual stuff' with her. She reports she hates living at home, but can't afford to move 
out." 
She reported to Dr. Kliman that her stepfather had a terrible temper, that she was fearful of him, and 
that when he would return home angry, she would remain in her room to avoid him and his anger. She 
reports on one occasion her stepfather struck her in the face. Her father also had anger control issues 
and police records note that he threatened to kill the mother during the time of their divorce. She 
reports that she had thoughts that her stepfather might be looking at her sexually after her contact with 
Mr. Epstein. 
3. Psychological reaction at the time of alleged trauma. 
reports that while she was with Mr. 
Epstein she was fearful, but she also notes that she was never specifically threatened, that she was able 
to advise him to cease behavior that she found unacceptable, and that she stepped away from him. She 
notes that she was angry that her friend 
had put her in that situation and she notes that she 
was tearful in the automobile when leaving the Epstein residence. She reports that after her contact 
with Mr. Epstein, she went on a "sexual extravaganza," began to think that her stepfather might have 
sexual interest in her, and began abusing multiple substances over a two-year period. She reports that 
she had sexual contact with approximately 35 people over a two-year period. There is a significant 
question as to whether these behaviors were caused by her one-time encounter with Mr. Epstein. Her 
therapist 
notes of 09/06/06 note the following "Does not feel she needs therapy for 
Epstein issue. Does not want to talk about it. Feels that it does not affect her in her life. She is 
unhappy at home. Feels home is very dysfunctional." During that visit she makes reference to her 
brother 
trying to do "sexual stuff" with her and her having to lock her door because she was 
fearful of him and his behavior. 
In addition, the family problems relate to her stepfather's temper and being displaced at home. She 
reports to Dr. Kliman that she was annoyed that her parents did not believe her when she reported the 
problems with 
inappropriate sexual behavior and was annoyed that it took similar behavior 
64 
EFTA01076570

Name: 
Date: November 17, 2009 
with her sister to cause them to take action. She reports that she felt that she had symptoms of ADD 
with problems with attention and concentration, focus, and task completion prior to meeting Epstein 
and her OCD symptoms began while she was in middle school prior to meeting Epstein. 
Her home environment was tumultuous and records show that her mother and father were engaged in 
marital counseling. 
4. Previous psychiatric/psvcholoaical histoty 
is not currently involved in psychological or 
psychiatric therapy. She reports she believes she had ADD as a child, but there are no specific records 
to substantiate that statement. She first entered therapy at age 18 with 
MS, a counselor 
who was also seeing her parents in marital therapy and perhaps individually. She saw Miss 
for 
about six months. Miss 
felt she was suffering from depression. Miss 
referred her to Dr. 
Agresti, a psychiatrist, for medication evaluation. Dr. Agresti started her on Prozac 10 mg, increasing 
to 20 mg, and made a trial with Zoloft, which she had to discontinue due to an allergic reaction. In 
addition, she received Ambien, Lamictal for mood stabilization, and Symbyax (Zyprexa and Prozac), 
an antipsychotic and antidepressant combination. Dr. Agresti felt she suffered from OCD, chronic 
depression, and a history of renal stones. 
Records note an episode of depression, perhaps beginning at 15 (report to Dr. Kliman); an overdose of 
seven pills of hydrocodone obtained following a wisdom tooth extraction, which was monitored by her 
mother but not taken to hospital; and an overnight admission to the 
Medical Center in 
Tennessee following a suicidal statement while arguing with her mother. There were episodes of self-
cutting reported, which heightened concerns. There was one visit with a counselor 
in 
Richmond, Virginia at age 19. 
There is a positive family history for marital discord. Her mother was married on three occasions. Her 
mother has a past history of depressive disorder. She reports that her mother also suffered from ADD 
and anxiety attacks and was excessively controlling and fearful that 
would be kidnapped 
or leave the home and never come back. She notes that her father had anger control problems. "He 
was an angry guy." As a child, there was family discord because she did not accept her stepfather and 
his role in the family. She described herself as a passive person who always needed to please others. 
65 
EFTA01076571

Name: 
Date: November 17, 2009 
She reports that she would often do things without thinking them through to please others. She notes 
that as a child (approximately age I I) she was concerned over frequent arguments in the house and a 
source of conflict focused on whose children were responsible for specific problems in the family. 
She notes that she would withdraw at that time, hang out with friends or go to her room to escape the 
arguments. She was worried about being "cool," fitting in with the other children, and being included. 
During her later adolescence, she considered herself a social butterfly. As noted, there were concerns 
of sexually inappropriate behavior by her brotherlii, who she found naked in her bed on one 
occasion and who would come into her room in the middle of the night and stare at her. She notes that 
on one occasion he was sexually inappropriate and touched her sister. 
As noted earlier, there were problems with polysubstance use and abuse, particularly from ages 17 
through 19. 
5. Previous victimization history. 
was fearful of sexual contact with her stepbrotheril. as 
noted earlier. 
6. Current and previous psychological difficulties. Records show tha 
feels that she suffered 
from ADD, as did her mother, but there are no specific records to confirm this diagnosis in her. She 
has been diagnosed, as noted, with OCD and depression. Many of her psychiatric symptoms are 
clearly specifically related to substance abuse (alcohol: sexual acting out behavior and blackouts; 
marijuana: diminished motivation, anxiety, and memory disturbances; Adderall: racing thoughts and 
euphoric-like states; cocaine: anxiety and depression, etc.). 
reports that her mood has 
been average and that she sees anxiety as the major thing that differentiates her from other people at 
this time. She rates her anxiety at a 5 on a 1-10 scale, with average people rating their anxiety at 3, 
where 10 is worst possible. She reports that she is currently functioning well while working at her 
parents' restaurant. She has future goals of attending school to study health and fitness. She is 
currently maintaining a relationship with her boyfriend even though separated by distance. She reports 
that she is living with her parents and that they arc getting along well at this time. She is generally 
optimistic about the future. There is some insecurity. She has concerns about fidelity with her 
boyfriend, who is on the skateboard circuit and has opportunities to have contact with multiple 
66 
EFTA01076572

Name: 
Date: November 17, 2009 
women, even though she doesn't believe that he is cheating on her. She reports that there is no 
suicidal ideation. There are no medical records to confirm any symptoms of PTSD, nor based on our 
current available information do we believe that she meets criteria for PTSD at this time. 
7. General personality dynamic and cooing style. The MCMJ-Ill suggests a personality diagnosis of 
Dependent Personality Disorder with Depressive Personality Traits, Borderline Personality Features, 
and Histrionic Personality Features. It suggests that there is a moderate level of pathology, which 
characterizes her overall personality organization and that she has defective psychic structures and a 
failure to develop adequate internal cohesion with a less than satisfactory hierarchy of coping skills. 
There is ineffective intrapsychic regulation and socially acceptable interpersonal conduct. The test 
suggests that she is likely to precipitate self-defeating vicious cycles of behavior, but that she is usually 
able to function on a satisfactory basis. The profile suggests that she is characterologically sad, 
markedly dependent, docile, self-effacing, and sees herself as ineffectual. She is dejected, tense, 
unable to function autonomously, and is especially vulnerable to separation anxieties and fears of 
desertion. (Her mother suffered from anxiety and was fearful that 
would be injured or 
kidnapped when she was a child. Her mother was overprotective brfluse of that.) There was a fear of 
abandonment and a loss of independence and self-assertion. 
The test suggests she may subordinate her personal desires to others and may submit to abuse and 
intimidation to avoid abandonment. She feels it is best to abdicate responsibility, leave matters to 
others, and place her fate in others' hands. She feels others are better equipped to shoulder 
responsibility than she is. The test shows a pattern of rapidly changing moods that shift erratically 
from normalcy to depression to excitement and chronic feelings of dejection and apathy interspersed 
with brief spells of anger, euphoria, and anxiety. The intensity of her affect and changeability of her 
actions are striking. 
dependent personality disorder is manifested by a pervasive and excessive need to be 
taken care of that leads to submissive and clinging behavior and fears of separation. This behavior 
may be a direct result of the interactions she had with her mother as a child. Her mother was fearful 
that she would be lost or kidnapped. The mother's excessive fear may have been internalized and 
subsequently produced a fear of separation and anxiety in the child. This behavior pattern usually 
67 
EFTA01076573

Name: 
Date: November 17, 2009 
begins by early adulthood and is present in a variety of context. Her dependent and submissive 
behaviors are designed to elicit caregiving and arise from a self-perception of being unable to function 
adequately without the help of others. MIlltotes 
that while growing up there were concerns in 
the family about who was responsible for conflict in the home, whether she had import, whether her 
parents would listen to her and accept what she said as truthful, and whether they would protect her 
(i.e., from her stepbrother MIsexual advances). 
Individuals with this personality disorder often have difficulty making everyday decisions and need 
excessive advice and reassurance from others. They tend to be passive and allow other people to take 
the initiative and assume responsibility for most major areas in their life. They typically depend on 
parents or spouses to decide where they should live, what kind of job they should have, which 
neighbors to befriend, etc. They have difficulty expressing disagreement with other people, especially 
those upon whom they are dependent. They feel so unable to function alone that they may agree with 
things that they feel are wrong rather than risk losing the help of those who they look to for guidance. 
They don't express normal anger for fear of alienating those upon whom they depend. They often 
have difficulty initiating projects and doing things independently and lack self-confidence. 
They wait for others to accomplish things, feeling that others can generally do them better. They are 
convinced that they are incapable of functioning independently and seek dependent relationships, 
often by engaging with members of the opposite sex. MIMI 
reports that she was sexually active 
because she thought that was what boys expected and required if they were to maintain a relationship 
with her.) They often function adequately if given the assurance that someone else is supervising and 
approving of them. They often fear becoming more competent, as they fear responsibility, failure, and 
subsequent abandonment Because they rely on others to solve their problems, they often do not learn 
the skills of independent living, thus perpetuating their dependency. 
They go to obsessive lengths to obtain nurturance and support from others, even to the point of 
volunteering for unpleasant tasks or placing themselves in a poor light. They are willing to submit to 
what others want, even if the demands are unreasonable. They need to maintain an important bond 
and this need often causes an unbalanced and distorted relationship. They may make extraordinary 
self-sacrifices or tolerate verbal, physical or sexual abuse. They tag along with others just to avoid 
68 
EFTA01076574

Name: 
Date: November 17, 2009 
being alone. When a close relationship ends, such as with the breakup of a lover or the death of a 
friend, they may urgently seek other relationships to provide the care and support they need, often 
throwing themselves into desperate situations. They believe that they are unable to function in the 
absence of close relationships and this often motivates them to become quickly involved and 
indiscriminately attached to other individuals. This was certainly the case described by MEI 
They see themselves as only functioning and being secure if there is another person in their lives upon 
whom they can depend. They often feel that they are totally dependent on the advice and help of the 
other important person in their life and they constantly worry of being abandoned by that person, even 
when there are no grounds to justify such fears. 
continually worries about whether her 
boyfriend will be unfaithful and abandon her. 
These individuals are characterized by pessimism and self-doubt, belittle their own abilities, have poor 
self-image and concept, diminish their own assets, and may refer to themselves as stupid. They take 
criticism and disapproval as proof of their worthlessness and often lose faith in themselves. They may 
seek overprotection or dominance from others. Occupational functioning is often impaired if 
independent initiative is required. They may have difficulty in school, where they have to make 
independent study decisions, such as in college. They may avoid positions of responsibility and often 
become anxious when faced with decisions. Social relationships are often limited to those few people 
upon whom they can be dependent. There is an increased risk of mood disorders, anxiety disorders, 
and adjustment disorders in individuals with this personality. Dependent personality disorder often 
coexists with other disorders, especially borderline personality, avoidant personality, and histrionic 
personality. 
Separation anxiety in childhood or adolescence may predispose to the development of this disorder. 
This was clearly the case with NM. 
Dependent personality disorders are among the most 
frequently reported personality disorders encountered in mental health clinics in this country. 
8. Sociocultural factors. 
has an extensive history of drug use and abuse. She grew up in a 
chaotic home environment, where she was fearful of her stepfather's anger. Her mother suffered from 
ADD, depression, and anxiety, and had separation issues with 
,vhen she was a child, feeling 
69 
EFTA01076575

Name: MEM 
Date: November 17, 2009 
that she might be kidnapped or, if she left home, that she might not return. She felt socially 
inadequate at times and tried to compensate for this by becoming a "social butterfly," but was 
continually worried that others may reject her or disapprove of her, especially if she said no. She 
performed adequately in high school, but had difficulty in college, where more independence was 
required. She described a chaotic family background, where she would withdraw to her room as a 
child, fearing the stepfather's anger. She had difficulty accepting her stepfather and felt that the 
family did not support her. There were times when she was fearful of sexual contact from her 
stepbrother, who had cerebral palsy. She was concerned that her complaints and concerns were not 
heard by the parents until similar complaints were made by her sister. She reports at least one episode 
where her stepfather struck her in the face. 
She had difficulty facilitating her autonomy and self-directed behavior. Her mother came from a 
background of inconsistent relationships with males and was married three times. MEI 
had 
early sexual contact, with the fast intercourse at age 15. She described a "sexual extravaganza" during 
later adolescence, when she was intimate with approximately 35 males. We note that individuals with 
dependent personality disorder often engage in multiple sexual contacts to maintain relationships. 
=IS 
reported that she felt she needed to be sexually active so that boys would accept her. 
There is an extensive history of drug use and abuse. 
Many of her more significant symptoms may be related to PANDA syndrome (pediatric autoimmune 
neuropsychiatric disorders associated with streptococcal infection). We note that 
had 
bilateral myringotomies and tubes placed in her ears. Such treatment is usually employed when 
children have repetitive earaches and streptococcal oropharangeal infections. Eighty percent of 
children with PANDA syndrome have obsessive-compulsive disorder and 50% have ADHD, both of 
which are reported to have occurred in-. 
Other neuropsychiatric symptoms commonly 
associated with PANDA include emotional lability; oppositional behavior; separation anxiety, which 
was significant in her case; bedtime rituals, which were reported; phobias; and a deterioration in 
mathematical skills and handwriting. We note that 
had considerable difficulty with 
mathematics. (She had a C in Algebra I in the 9th grade first and second semesters, Bin Algebra,' in 
the 11th grade first semester, and F during the 11th grade second semester. During her senior year, she 
received a D in liberal arts mathematics.) 
70 
EFTA01076576

Name: 
Date: November 17, 2009 
She reports current improvement with her OCD, which is also characteristic of this condition, as OCD 
of PANDA often improves with age rather than deteriorate. Tics that occur in approximately 12% of 
the children with this syndrome are usually transient and have estimated onset prevalence of only 1-
2%. 
PANDA patients who have ADD/ADHD and/or OCD often have courses that are complicated by 
either aggressive or disruptive symptoms or social or academic failure. Current mood and anxiety 
disorders often aggravate the course of the condition. With PANDA syndrome, tics, if they occur, 
usually begin at around age 7 or 8. Exacerbations occur days to months after the onset of the 
streptococcal infection. As noted, up to 12% of children may have tic syndromes; the remainder do 
not. The interval between first streptococcal infection and the appearance of symptoms may be weeks 
to months, but subsequent infections have shorter intervals between the infection and symptoms' 
exacerbation, often only a few days or weeks. PANDA can be triggered by simple exposure to people 
with streptococcal infections, but without apparent clinical symptoms until the appearance or 
exacerbation of the neuropsychiatric syndrome. 
Teasing, shame, self-consciousness, and social ostracism are common features in patients with 
predominantly internalizing comorbidities where antisocial or criminal outcomes may be 
manifestations with prominent externalizing cormorbidity. Some of these patients show reluctance to 
involve themselves in socially demanding situations, particularly if their symptoms are perceived by 
themselves to be socially disfiguring. During childhood and adolescence, they may be avoidant of 
contact and they may avoid long-term intimate relationships, marriage, or other interpersonally 
gratifying activities. Children with PANDA often present with ADD, ADHD, conduct disorder, OCD, 
or learning disorders. There is often a positive family history for ADD, ADHD, OCD, or 
streptococcal-related illnesses. Children are often self-conscious, sensitive to being teased or socially 
ostracized. They often have concurrent mood or anxiety disorders. The condition is often made worse 
by family psychopathology and stressors. 
The condition can be diagnosed by analyzing antibodies to streptococcal enzymes, streptolysin o, and 
DNase B. Throat and nasopharangeal swabs at the time confirm an acute infection. Monoclonal 
71 
EFTA01076577

Name: 
Date: November 17, 2009 
antibody 8D/17 acts as a trait marker for susceptibility. Neuroleptic drugs are effective in treating 
these children and adults. 
Currently, atypical antipsychotic medications produce 60-80% 
improvement. Clonidine is helpful in approximately 50% of these patients. Guanfacine, an alpha 2 
adrenergic receptor agonist, has also been found effective. 
IMIllreports she had her adenoids removed when she was in the 6th grade and notes that her 
OCD began in middle school, which would be entirely compatible with a relationship to streptococcal 
infection. 
9. Level of emotional support. describes 
coming from a family with poor emotional support. 
Her parents divorced. Her mother remarried. There were seven children in the family. She felt that the 
family did not accept her fears and concerns as they related to her brother as realistic and felt the need 
to withdraw to her room to protect herself from violent family arguments and her stepfather's unstable 
temper. She was fearful of being sexually abused by her brother and felt that these concerns went 
unrecognized and unsupported until her sister made similar complaints. There was a history of family 
instability, impaired child/parent relationships, and parental adjustment difficulties with her mother 
and stepfather seeking therapy. Her mother had trouble with separation from her and was excessively 
fearful, a behavior that 
may well have learned. Her brother was involved in the sale of 
hallucinogenic drugs. She sought peer support through social interactions, but was fearful of not 
going along with the expectations of others. 
SUMMARY: 
We believe within reasonable medical certainty that Miss 
suffers from 305.90 Psychoactive 
Substance Abuse, NOS (Percocet, age 19; Adderall, age 20; nitrous oxide whippets, age 20; Xanax, age 19; 
Alcohol age 17; marijuana, age 17; cocaine, age 21; LSD, age 19; and hallucinogenic mushrooms, age 21); 
296.90 Mood Disorder, NOS. Rule out Substance-induced vs. Bipolar Disorder; 305.00 Alcohol Abuse with 
frequent symptoms of severe alcohol intoxication, vomiting, and blackouts; 300.3 Obsessive-Compulsive 
Disorder, by history, accompanied by significant anxiety, age 18, Dr. Agresti; Rule out PANDA syndrome 
(pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection); History of bilateral 
myringotomies; adenoidectomy; questionable ADD, anxiety, OCD; and 311 Chronic Depression by history, 
age 18, Dr. Agresti. 
72 
EFTA01076578

Name: 
Date: November 17. 2009 
SPECIFIC QUESTION TO BE ADDRESSED: 
Estimate impact of involvement with Jeffrey Epstein as a causative factor in 
symptoms and 
behavior, Although it is impossible to provide an exact figure as to the impact that the contact with Mr. 
Epstein has had, after reviewing all factors in 
life and her extensive history, we believe that she 
did react emotionally to the contact she had with Mr. Epstein at the time. Her dependent personality disorder, 
which we believe existed when she saw Mr. Epstein, would have made it more difficult for her to say no and 
her report that she felt apprehensive, we believe, is creditable. There are discrepancies in her recounting of her 
family history and dynamic given to different reviewers. Her report suggests that her symptoms of difficulty 
with attention, concentration, focus, ability to maintain tasks, anxiety, and obsessive-compulsive behavior and 
thoughts preexisted contact with Mr. Epstein. 
Her increased substance use and abuse and sexual excesses are more consistent etiologically with her 
dependent personality disorder and the need to please and be accepted by others, particularly young males, than 
by any reaction to her 30-minute contact with Mr. Epstein. Her concerns that her stepfather might see her as a 
sexual object, however, may be related to the contact with Epstein. It is more creditable that her fear of 
abandonment and mistrust of males are related to her dependent personality disorder than to the specific 
occurrence with Epstein. Her mood dysregulation, impaired motivation, and some of her anxiety and 
depression, as well as what were seen as potentially bipolar symptoms, we believe are clearly substance related. 
She reports that she was partying every night, looking for alcohol and to become inebriated. She abused 
amphetamines, hallucinogens, marijuana, cocaine, other narcotics, minor tranquilizers, and inhalants. 
In addition, we believe that her unstable home, difficult relationship with her stepfather, fear of her father and 
stepfather's anger, and fear that she might be sexually abused by her stepbrother-, who suffered from 
cerebral palsy, were other important factors. We note her report to her therapist that she did not believe that 
the episode with Mr. Epstein was significant in producing her symptoms and that she related her symptoms at 
the time to conflict in her family environment. All these factors, within a reasonable medical certainty, have 
had a more profound impact on her than the contact with Epstein. 
73 
EFTA01076579

Name: IIMEM 
Date: November 17, 2009 
In estimating the percentage of impact of Mr. Epstein's behavior on her total psychiatric picture, one would 
estimate 0-5% causative. 
'The above opinion is rendered within reasonable medical probability. 
Respectfully submitted, 
Ctil °I A 
Sidi 
Ryan C. W. Hall, MD 
RCWH/nlic 
74 
4-;:i
4 /1
ll 
Richard C. . 
I, MD 
EFTA01076580