COMPREHENSIVE PSYCHOLOGICAL EVALUATION

NICKALAUS STOUTZENBERGER

MAY 10, 2013



Identifying Information

Birth Date: 09/01/91

Gender: Male

Age: 21 years, 8 months

Race: Caucasian



Community Systems Involved:

TEAMCare Behavioral Health, LLC: Therapist - Tara Tumility; Psychiatrist - Dr. Biever

Community Services Group, Intensive Case Management - Chad Wickenheiser



Reason for Referral

Nick was referred for a comprehensive psychological evaluation by his outpatient therapist, Tara Tumility, to clarify diagnosis and to determine if Nick's demonstrated social weaknesses may be related to cognitive defects, personality factors, and/or a developmental disability.



Relevant Information



Background History



Strengths



Nick is a 21 year, 8 month-old Caucasian male, with self-reported strengths that include an interest in music, writing and drawing. Family strengths include a supportive maternal aunt who provides housing and money management for Nick. She has also arranged for a variety of services for him. These areas of individual and family strengths represent domains that can be further developed for use as a foundation for a strength-based plan.



Family



Nick is presently living alone in an apartment in Columbia, PA which is owned by his maternal aunt, Joyce. He has never married and he has no children. His parents are divorced; his mother is remarried and his father resides with his girlfriend. Both his parents live locally, but Nick reported that he does not see them often. He reported that his mother and step-father will not allow him to come to their house although Nick reported that he does not know what prompted that decision. When he inquired about this to his step-father, Nick indicated that his step-father said, "You know why." Nick reported that he does not like his mother or step-father because "they are very conservative and not very tolerant." He acknowledged that his aunt, Joyce, is his primary social support, but he reported that he does not have a good relationship with her. His main source of conflict with her is that she controls his money and will not allow him discretion with his purchases; specifically she will not allow him to purchase women's clothing for himself. Nick did report that he was in agreement with her being his representative payee because he feels that he would not be capable of managing his own money.



Nick does have a 10-year-old maternal step-sister and he reported that he has a good relationship with her, but he is not allowed to see her without a parent present. He denied any past violence or inappropriate behavior towards her.



Nick lived with his biological parents until they divorced when he was a young child. Nick reported that he does not recall much about his childhood, although his aunt reported that his father was alcoholic, abusive, and unpredictable. His aunt could not recall any specific incidents. Nick remained living with his mother when his parents divorced and after his mother's second marriage. Nick was homeschooled for a period of a couple years in high school. His aunt, Joyce, was his primary instructor. After Nick completed high school, his aunt assisted him in applying for social security disability, helped him to get connected with a mental health case manager, and allowed him to live in an apartment that she owns.



With regard to his living situation, Nick has concerns about his ability to live independently. At one point, his voice became loud and he appeared to be in distress and stated, "Why would these people even think I could live alone?" He reported that he is fearful to leave his house or to answer his door. He acknowledged that his decision-making skills are poor at this time. When asked what he would do if there were a fire on his stovetop, he responded, "I would have to text my aunt." When further prompted, he said maybe he could put something over the fire because he did not think you could throw water on a stove, but at no point did he mention calling 911 or using a fire extinguisher.



In terms of family psychiatric history, his aunt reported that his maternal grandmother was diagnosed with dementia recently and may have previously been diagnosed with bipolar disorder. Some extended cousins are reported to have been diagnosed with bipolar disorder. Family substance abuse is significant in that Nick's father was reportedly an alcoholic and according to Nick, his father also abused marijuana, allowing Nick to smoke with him.



Cultural Considerations



Nick's family composition is Caucasian. There is no report of any adverse impact as a result of cultural factors. There is no report of any negative impact due to environmental factors. Nick reported some concerns with his finances as he is currently receiving Social Security Income. Nick indicated that he does not have a religious affiliatio.



Developmental/Medical



Several attempts were made to reach his mother, Carol Osborne, to obtain developmental and collateral information. His mother could not be reached directly, but she did leave a message reporting that "he has always been a problem." His aunt, Joyce, did not recall any problems during his mother's pregnancy or his delivery. She did not recall that he had any developmental delays and commented that "he was always pretty smart." There is no indication that Nick ever received any early intervention services. By his own report, he was able to read prior to entering kindergarten.



Medically, Nick reported that he does not have a primary care physician. He denied any history of seizures, head trauma, unusual illness, or medical hospitalizations. He is not aware of any allergies to medications or environmental agents. He is not being treated for any medical problems. He did report concern about a chronic cough, but reported that he was told by a physician that it was likely due to allergies. He is presently prescribed Viibryd for anxiety and depression and he also has a PRN prescription for Ativan which he reportedly uses two times per month when he goes grocery shopping. He reported that he takes his medication as prescribed and follows with Dr. Biever, his psychiatrist, on a regular basis.



Trauma History



With regard to trauma, Nick denied any history of sexual, physical, or emotional abuse. He denied any history of neglect. Nick's aunt, Joyce, reported that when he was young and his parents were still married and living together, his father would frequently come home intoxicated and would be verbally abusive and destructive to property. His aunt also recalled an incident where Nick's father spanked him at school and "somebody checked into that." Nick's parents divorced sometime during his elementary school years, although he could not recall what age. He continued to live with his mother and visited with his father on a regular basis. Nick has not been involved in any human-made or natural disasters.



School/Vocational



Nick attended Penn Manor School District and paperwork from this district indicated that he was placed in full-time emotional support in 4th grade, although a copy of his psych-educational evaluation is not available for review. His present educational levels during the 2001-2002 school year noted the following: "Nick is usually very quiet in class and at times cooperative in class. He works well in 1:1 situations with staff and in small groups. He receives 48 to 52 points per day on his point sheet (52 possible points). Nick loses the most points in the area of respect and class rules. He continues to exhibit difficulty with peer relationships which is demonstrated by his inappropriate behaviors to peers. Until recently, Nick did not interact with others on the playground and often chose to remain in the classroom during recess. He is unable to accept consequences for his inappropriate actions, and repeatedly states, 'I didn't do anything.' Nick is extremely emotional and takes everything to heart."



His strengths were noted to be superior intelligence, creative talents, visual sequencing, wide vocabulary skills, verbal reasoning skills, abstract reasoning abilities, academic abilities. His needs were described as increase compliance with school rules/expectations, increase appropriate social interaction with peers, specifically to lessen physical aggression toward peers, increase ability to seek help when needed and to develop strategies to deal with anxiety and withdrawal.



There is no other school information available until he returned to Penn Manor High School as a junior. Nick was homeschooled during his 7th, 8th, 9th, and 10th grade years. When Nick returned to the public high school, he was enrolled in full-time emotional support. Information from his IEP that year noted, "since enrolling in Penn Manor School District as a junior, Nick has been doing very well academically and behaviorally." Observations indicated that "his teachers describe Nick as quiet, intelligent, and funny. In class, Nick will sit quietly and rarely offer answers or participate in class discussion without teaching prompting." It is also noted that, "Nick needs to improve his social skills. Nick avoids high social areas such as the cafeteria and hallways, even with peer prompting to join. Nick sometimes makes comments or acts in ways that has a tendency to draw negative attention to himself - such as sucking on his hair or moaning for no apparent reason."



Nick reported that when he was younger, he would frequently get into fights with his peers at school. He could not recall if he initiated the fights. When he returned to school as a junior, Nick reported that he spent most of his time sitting at a desk drawing and peers would approach him to talk and/or comment on his drawings. He described these peers as his friends but reported that he never had contact with them outside of school by his choice.



Transition planning indicated that Nick's future goal was "to be a househusband and Nick has given little thought to other options, even with prompting from the teachers and the job trainer."



Nick graduated high school, although he cannot recall the exact year. He thinks it was 2008 or 2009.



Vocationally, Nick has helped his mother at her flea market stand a couple times, but other than this he has no employment history. He is presently receiving social security disability based on his diagnosis of major depression.



Community/Peer Relationships



Nick does not have any peer relationships in the community. He has a strained relationship with his family members. He developed a relationship with some individuals online when he was a teenager. One individual is "Anna" and she has blocked all contact with him, although he continues to make attempts to contact her electronically. Nick firmly believes that he and Anna will eventually marry and he continues to ignore her request to not contact her, and the more recent request of the police, to stop all contact with her. He believes that she resides in California, but stated that he has no plans to go to California to find her "because I would need an escort because I wouldn't know how to go about getting there." He also reported that he will continue to try to contact her, although "I wouldn't commit a major crime to reach her, but probably a misdemeanor." He continues to have frequent contact with a young woman, "Jessa," and Jessa's fiancé, "William." Nick refers to Jessa as his mother, but reported that he does not really like William, but maintains contact with him because of Jessa. Reportedly Jessa is his age. He commented how he had gotten her some coupons for Mother's Day. There is another individual, "Thom" who Nick met online and Nick refers to his as his father.



With regard to intimate relationships, Nick reported that he has never had a girlfriend that he has met in person and he reported that the only girlfriend he has ever had is "Anna", although he has only had electronic communication with her and it is not clear if she ever reciprocated his feelings. Nick has never been sexually active with a female or male and he reported that he regards himself as heterosexual. He reported that he has crossdressed since he has been a teen, but he does not currently have access to women's clothes. He reported that he frequently masturbates and that he feels his sex drive is "more active than most people." He enjoys pornography that involves feces and he reported that he frequently fantasizes about having anal sex, consensually and forcibly with females. He also reported that his sexual fantasies include young girls who "can talk in full sentences and are house-trained, but not yet like real women." He denied that he has ever approached or had any sexual contact with a minor. He admitted that he tried to find female child pornography online in the past, but he was reportedly unsuccessful. When this evaluator told him that this type of activity is illegal, he indicated that he did not understand why that would be.



Nick is not involved in any community activites and reportedly only leaves his apartment to go to appointments and to grocery shop two times monthly. He spends the majority of his time at home alone, communicating with the above individuals electronically. Nick reported that he does not recaqll ever engaging in any community or school activites.



Drug & Alcohol/Legal



In terms of substance abuse history, Nick reported that he used alcohol one time several years ago while with his father. He consumed one "Jell-O shot". Nick reported that he used marijuana approximately 20-30 times with his father when he was a young teen. He reported that he has not used marijuana in at least 4 years. He denied any history of using any other type of substance. He denied any history of abusing prescription or over-the-counter medication and he does not take any herbal supplements.



In the legal sphere, Nick reported that he was arrested twice as a juvenile. His memory of the exact indicents is not clear, but he believes both incidentes may have been related to aggression and/or threats to his mother. He stated that he was on probation for these incidents. He denied any arrests as an adult. He was aware that the police had recently contacted his aunt related to his attempts to contact a female via the Internet, but he reported that "they did not approach me directly." He reported that he has continued to try to contact a female, "Anna", despite her direct request that he not contact her and she has blocked all communication from him.



Service History



Nick received inpatient psychiatric treatment at age 15 for 11 days at Brooke Glen Behavioral Hospital. He was involuntarily committed after he became physically aggressive with his mother. A discharge summary from this facility indicated the following diagnoses: major depression, social phobia, avoidant personality traits. It further stated that, "psychological testing was completed which supports the above diagnoses, it did not support psychosis." During his hospitalization, anti-depressant medication was recommended but "mother did not indicate that she would follow through with this option for aftercare."



Other than school interventions and his current treatment, it appears that Nick's hospitalization represents the extent of his previous formal psychiatric treatment. Nick reported that his mother does not believe in mental illness and, therefore, she did not initiate or support treatment.



Evaluation Procedures



Review of the following records:

Clinical interview with Nick Stoutzenberger

Consult with Tara Tumility and Chad Wickenheiser

Brief phone interview with his maternal aunt, Joyce

Behavioral observations

Wechsler Abbreviated Scale of Intelligence (WASI-II)

Wechsler Individual Achievement Test, Second Edition Abbreviated (WIAT-II)

Thematic Apperception Test (TAT)

Minnesota Multiphasic Personality Inventory-2 (MMPI-2)

Delis Kaplan Executive Function System (D-K EFS)



Interview/Test Results



Behavioral Observations



Nick was brought to the appointment by his case manager, who dropped him at the office. Nick is tall and he has a large build. He was dressed casually and appropriately, although he was malodorous. He had a beard and his hair was slightly unkempt. Nick reported that he generally only showers once a week. His eye contact was fleeting and he appeared to try to avoid eye contact, often looking down. His activity level was within normal limits. He was able to initiate and sustain attention for all tasks and his concentration was adequate. He did not require any repetition of directions. He demonstrated good manners, never interrupted and was able to engage in a reciprocal conversation. He answered all questions, at times offering relevant spontaneous information. He was able to complete the entire evaluation in one day, taking a 20 minute break for lunch. After he completed the evaluation, he thanked the evaluator.



Mental Status Exam



In terms of mental status, Nick was alert and was oriented to person, day of the week, month, year, and situation. His affect was constricted. He described his mood as "depressed, scared, and bored." Stream of thought appeared to be organized, relevant, and goal-directed with content of thought focused on providing information as requested and completing the tasks required. His responses were relevant to the questions. Nick did not exhibit any overt indications of an underlying thought disturbance, in the form of auditory or visual hallucinations, and he denied that presence of both, in the present or past. He denied present suicidal ideation. He reported that he has experienced suicidal thoughts in the past, "but I would never do it." Nick reported that he constantly has homicidal ideation toward his mother, step-father, and aunt; however, he stated adamantly that he has no intent to act on these thoughts because "I do not want to go to jail." He indicated that he frequently has "videos" playing in his mind that involve killing his family in multiple ways, indicating that sometimes he is portrayed as a superhero in these "videos." Nick reported that he has been violent with his mother in the past and has left bruises on her. When he was fifteen, he was psychiatrically hospitalized after he assaulted his mother because she would not allow him to use the computer. Nick denied any history of cruelty to animals, vandalism, or fireplay, adding that he is very close to his cat and wondered what life would be like if he could communicate with his cat by speaking "cat language." His insight was fair as he indicated that he has pursued therapy, psychiatric treatment, and psychologcal testing "because I want to know what's wrong with me." His judgment is extremely impaired as he reported that he does not understand why anyone would be concerned with his constant attempts to contact a female that does not want contact as well as his claims that he will certainly marry this female. Additionally, he showed this evaluator, as well as his therapist, conversations that he has had online with others that contain graphic sexual and violent comments and he does not understand why this is considered inappropriate or unusual.



Validity Considerations



The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) yielded an invalid profile based on Nick's endorsement of far more symptoms than would be typical even for an individual being treated on an inpatient psychiatric unit. High scores on most scales as evidenced by Nick's profile suggests that an individual may be overly endorsing problems in order to appear pathological or, as likely in Nick's case, it is an indication that an individual is experiencing a myriad of symptoms in several domains, frequently and intensely, and that the symptoms are causing a significant amount of stress and impairment.



Intellectual Functioning



The Wechsler Abbreviated Scale of Intelligence, 2nd Edition (WASI-II) administered in order to assess Nick's cognitive functioning and to obtain and understanding of his level of intellectual functioning. The WASI-II is designed as a screening tool to quickly and accurately estimate an individual's intellectual functioning. Assessment of Nick's present level of cognitive abilities indicates overall intellectual functioning in the superior range (WASI-II IQ = 129). Nick's IQ places him in the 97th percentile, indicating that he did as well or better than 97% of similarly aged individuals. Nick's verbal skills are significantly more developed than his nonverbal skills, although his nonverbal abilties, as evidenced by his performance on the Perceptual Reasoning Index, are solidly within the average range.



WASI-II SUMMARY SCALES (Mean = 100, SD = 15)

Scale - Composite Score - Percentile - Confidence Interval (95%) - Description

Verbal - 143 - 99.8 - 135-147 - Very Superior

Perceptual Reasoning - 108 - 70 - 101-114 - Average

Full Scale (Four subtests) - 129 - 97 - 123-133 - Superior



WASI-II SUBTEST T-SCORES (Mean = 50, SD = 10)

Vocabulary: 77

Similarities: 75

Block Design: 58

Matrix Reasoning: 52



With regard to specific subtests, Nick demonstrated abilities above the norm on all subtests. His best performance was on the Vocabulary subtest, as his score fell well above the norm. This subtest assesses an individual's expressive vocabulary, verbal knowledge, and fund of information. His performance on the Similarities subtest was equally as strong as his performance on the Vocabulary subtest. The Similarities subtest measures abstract verbal reasoning and conceptualization. Nick's performance on the Block Design subtest was above the norm. This subtest measures spatial visualization, visual-motor coordination, and abstract conceptualization. Nick also performed in the average range on the Matrix Reasoning subtest, which measures nonverbal fluid reasoning.



Achievement



In order to assess Nick's level of academic achievement, the Wechsler Individual Achievement Test - Abbreviated, Second Edition (WIAT-II Abr.) was administered. Nick's performance on the Word Reading subtest was in the high average range of scores (SS = 112). He was able to read all the words on the list with the exception of "ethereal" which he slightly mispronounced. His performance on this subtest correlates to a 12.8 grade equivalent. His score on the Numerical Operations subtest was in the average range (SS = 103). This score corresponds to an 11.9 grade level. His performance on the Spelling subtest was in the high average range (SS = 114) and corresponds to a 12.8 grade level.



Neuropsychological Functioning



In order to further measure Nick's executive functioning abilities and his higher level cognitive skills, various tests were administered to obtain a clearer picture of his strengths and weaknesses in these areas. The Delis-Kaplan Exsecutive Functioning System (D-KEFS) is a measure of high order cognitive, executive functioning. The subtests were designed to assess complex multifactorial domains of cognition in a comprehensive manner. The D-KEFS subtests administered include Trail Making, Verbal Fluency, Sorting Test, Twenty Questions, and Proverb Test.



Trail Making Test - Scaled Score - Classification

Visual Scanning - 12 - At Expected Level

Number Sequencing - 13 - Above Expected Level

Letter Sequencing - 12 - At Expected Level

Number-Letter Switching - 11 - At Expected Level

Motor Speed - 13 - Above Expected Level



Nick's performance on Trail Making, which involved visual cancellation and connecting circles tasks, demonstrated average to above average abilities in cognitive flexibility, a classic executive function that is essential for higher-level skills such as mulititasking, simultaneous processing, and divided attention. His motor speed was faster than would be expected and his ability to visually scan information was at the expected level. His ability to sequence numbers was above the expected level and his ability to sequence letters was average. His ability to shift between numbers and letters, requiring cognitive flexibility and divided attention, is in the average range.



Verbal Fluency - Scaled Score - Classification

Letter Fluency - 7 - Borderline

Category Fluency - 7 - Borderline

Category Switch - 8 - At Expected Level

Category Switching Accuracy - 9 - At Expected Level



The Verbal Fluency Test requires word generation based on letter and category, with a switching task also presented. Nick's ability to generate words starting with a specific letter is slightly below what would be expected. He appeared to be anxious during this task and some of the words were associated with sexual activity such as "fornication" and "syphilis." His ability to generate words that fit into a specific category is slightly below the expected level; however, his ability to cognitive shift between categories is at the expected level with his accuracy on this task at the expected level as well.



Sorting Test - Scaled Score - Classification

Confirmed Correct Sorts - 14 - Above Expected Level

Free Sorting Description - 15 - Above Expected Level

Sort Recognition - 16 - Well Above Expected Level



On the Sorting Test which measures concept-formation and verbal and nonverbal problem solving abilities, Nick performed in the range above what would be expected for an individual his age. His performance on this measure suggests that his ability to think abstractly and solve problems is very well developed.



Twenty Questions - Scaled Score - Classification

Initial Abstraction Score - 9 - At Expected Level

Total Questions Asked - 13 - Above Expected Level

Total Weighted Achievement - 19 - Well Above Expected Level



The Twenty Questions Test measures abstract thinking and problem solving strategies. The executive functions assesed include the perception of various categories and subcategories represented; the ability to formulate dichtomous questions, and incorporate feedback to formulate more efficient questions. Nick was shown a page of various common items and objects and he has to ask yes/no questions to determine the target object. The goal was to ask as few questions as possible in order to identify the target object. Nick's performance on this measure is consistent with his performance on all other measures of abstract thinking and problem solving, suggesting that these higher level thinking skills are very well developed in this young man.



The Proverb Test evaluates the abstract interpretation, understanding of word meanings, as well as abstract principles and concepts. Nick's ability to verbally describe proverbs was in the expected range and when provided with a proverb and multiple choice answers, he correctly answered 100% of the questions.



Emotional and Behavioral Functioning



While Nick's cognitive, achievement, and higher level executive functioning abilities are impressive, his emotional and behavioral functioning is concerning. In the clinical interview, Nick reported that he has "videos" playing in his head where he is able to view himself killing his mother, step-father and aunt in various ways. He reported that at times it is him in his natural state killing them and other times, he becomes a superhero with superpowers and kills them. Nick casually described how he feels they deserve to die because they are very conservative and not tolerant of other races and homosexuals. He stated that they don't like him because he likes sex, violence, and cursing. Nick clearly stated that he has no intent to kill his family, "because I don't want to go to jail," but he further stated that if no laws prohibited murder, he is sure he would do it.



Nick also reported having sexual fantasies that involve him having anal sex with women and young girls. He reported that his fantasies include both rape and consensual sex. His sexual fantasies involve feces as he reported that he becomes sexually aroused by fantasizing about women defecating and that he has used feces when he masturbates. He does frequently view pornographic tapes that involve the above, although he reported he has not been able to access child pornography. He stated that he has never been sexually intimate with anyone. His only sexual encounter was around the age of thirteen when he and a female teen cousin touched each other and this was reported to be consensual. Nick shared his journals with this evaluator which included numerous writings about sex and violence. He had written about being angry with his aunt and described how he would like to anally rape her. He reported that he does not necessarily fantasize about his aunt and that he wrote that statement out of anger. At one point, he wrote how something was falling from the sky and he thought it was semen, but later realized that it was rain. On the MMPI-2, Nick's responses on the Schizophrenia scale were quite high (T = 112). Specifically, his high score on the social alienation subscale (T = 105) suggests that he perceives that he is mistreated and misunderstood. His emotional alienation score (T = 98) indicated that he has a significant amount of fears, depression, and apathy. Additionally, the high T scores on the Lack of Ego Mastery, Cognitive (T = 90) and Conative (T = 92) scales are consistent with someone who fears losing control, feels as though life is unreal and likely responds to stress by retreating into a fantasy world. His responses on the Thematic Apperception Test (TAT) suggested some problems with reality orientation. He described one picture as a house in a snowstorm with "eyes" in the background "that's like a ghost or something." On another card, he saw a figure in the background and stated, "that's like a dog wearing a hood" but later added that he did not know why a dog would be walking upright, wearing a hooded jacket.



With regard to his impulse control, Nick reported that he feels he can control his impulses but attributed part of that to his fear to leave his home. He did state that he has some concerns about decreasing his social anxiety because "If I'm cured and go out, I fear what I would do." While Nick's explosive anger score is elevated (T = 71) his score on the inhibition of aggression score is average (T = 48), which supports Nick's assertion that at the present time he is successfully controlling his angry impulses.



Nick described a significant level of social anxiety, which he has experienced for several years. He reported that he did not want to go to school and that is why he was homeschooled from 7th to 10th grade. When he did return to public school, he reported that his attendance was good, but he did not like to leave the classroom. He reported that he does not like to be in the community because he is worried about being harmed or shot. He does not feel safe in his home, "I'm afraid of everything, I feel like I can't defend myself and I don't know what I would do if someone broke in." He also reported that he does not like to take showers because he becomes increasingly fearful during this task. He reported that he has difficulty talking to others in the community and that he has signigicant problems making decisions, "I have trouble placing an order at McDonald's." Nick was able to describe appropriate social behavior and described being socially avoidant because he becomes so anxious around others that he cannot function or communicate. He indicated that he is aware that some of his anxiety resolves around his fear of what he may do to others if he cannot control his impulses. Nick's overall score on the paranoia scale on the MMPI-2 was extremely elevated (T = 101) with responses that corresponded to a signigicant amount of persecutory ideas (T = 112). His responses on the TAT also include some persecutory ideation. He described story about a picture with a young boy and broken violin as "it's broken at the neck; someone probably did it on purpose." Another card showed a little boy sitting alone and he described the boy as "upset" and that "maybe his parents punished him and he's in trouble." Another picture he described as "a bunch of dudes huddled together for safety or warmth" noting that one man is "probably the watch, they probably sleep in shifts."



With regard to his mood, Nick stated that he is generally depressed. He often feels hopeless, but indicated there are times when he is hopeful; mainly when he fantasizes about "Anna." He described feeling worthless, "I'm not really good at anything, I can't contribute to society." He indicated that he never cries, "but I feel like I need to, I just don't." His personal hygiene is very poor, he showers once per week with prompting and does not attend to his personal care consistently. He described his sleep as "random" but indicated that he is working on trying to establish better sleep habits by going to bed at 10 or 11 and then he typically sleeps until 9 AM. He reported that his appetite is good. He denied present suicidal ideation, but noted that he has had these thoughts in the past, but has never made a suicide attempt. Nick's score on the MMPI-2 depression scale is elevated (T = 91) with elevated scores on scales that assess subjection depression, psychomotor retardation, physical symptoms, mental dullness, and brooding. Nick has previously been diagnosed with major depression and he is currently being treated for anxiety and depression with therapy and medication.



Discussion



One of the purposes of this evaluation was to assess Nick's cognitive functioning as he demonstrates extremely poor judgment and decision making skills and his adaptive functioning is marginal. However, Nick's intellectual ability is in the superior range, with very superior verbal skills. His verbal skills are significantly more developed than his nonverbal skills; which is sometimes the case in individuals with Asperger's disorder; however, Nick does not demonstrate any deficiencies in academic achievement as if often co-morbid in inidividuals with Asperger's disorder, nor does he show any deficits in his higher level thinking skills. Quite the contrary, Nick demonstrated well developed abstract thinking, problem solving, cognitive flexibility, and the ability to sustain divided attention. Typically, individuals with Asperger's disorder demonstrate areas of relative weakness in some areas of higher level thinking.



Although limited past information was available for review, the information from his school and from his inpatient stay at age 15, does not mention any consideration of a diagnosis of Asperger's disorder and reported his problems with socialization to be primarily related to his social avoidance and social phobic behaviors. Presently, Nick demonstrates a marked fear of all social situations because he feels he does not know how to communicate and behave in these situations. When he is required to attend certain places, such as the grocery store, he reported that he needs to take Ativan to avoid a panic attack. Nick understands that his anxiety is well beyond what is typical and acknowledged that he is in no more danger than anyone else. His anxiety has significantly negatively impacted his ability to function in all domains including social, occupational, academic and interpersonal. Based on these symptoms that have been present for several years, a diagnosis of social phobia will be assigned.



Nick has demonstrated a pervasive pattern of social interpersonal deficits evidenced by his extreme discomfort with social interactions and his inability to develop close relationships. In addition, he also has cognitive distortions. He believes his family should be murdered because of his perception that they are "too conservative." He continues to be obsessed with a female, "Anna" that he met on the Internet and firmly believes she will be his wife despite her consistent refusal to have contact with him and police involvement. The relationships that he has developed on the Internet, based on his journal writings and the dialogue, appear to revolve around his expression of sexual and violent desires. These relationships seem to have a surreal quality to them as he described one female as his mother and another individual as his father and looks to them for parental advice. He demonstrates obsessive ruminations with explicit sexual and aggressive content and does not seem to understand that this is atypical, especially his focus on discussing his intense dislike for vaginas. His speech, although well developed, can be circumstantial and odd as when he described young girls as "being house-trained and able to speak in complete sentences." His affect is constricted and he demonstrates little to no emotion, he lacks close friends, and his social anxiety is pervasive and seems to be more associated with fears of being harmed rather than on negative judgments about himself. Based on records from the school and his previous hospitalization, as well as his report and his aunt's collateral information, these behaviors have been longstanding and likely represent a maladaptive personality disorganization. Based on these symptoms, Nick meets criteria for schizotypal personality disorder. While some of his behaviors are consistent with avoidant personality disorder, his social anxiety does not primarily seem to be the result of the fear of rejection. Additionally, his cognitive distortions and odd beliefs are more consistent with a schizotypal personality organization.



While Nick reported that his "friends" from the Internet have suggested to him that he has Asperger's disorder and he also feels this may be the case, there is limited historical information to support this diagnosis. Additionally, his performance on tests of higher level thinking skills indicated that his abstract reasoning, problem solving skills, and cognitive flexibility are very well developed, which is not typical. His problems with socialization appear to be more related to social anxiety and fears, rather than an inability to understand social cues or a lack of understanding about appropriate social behavior.



Nick has previously been diagnosed with major depression and he clearly meets criteria for this disorder at this time. He described that he has a pervasive depressed mood and finds little enjoyment in any activities. His functioning in all domains is impaired and he has great difficulty making simple decisions. His self-care is marginal, although he understands what activities of daily living should be completed, knows how to do them, and can functionally perform these tasks; he does not. He feels hopeless and worthless most of the time and has little motivation and energy. It appears that he has had several episodes of depression since at least his teen years, with few periods of remission. He reported that he feels little benefit from the medication.



With regard to his perported sexual arousal related to touching or viewing feces, he will be given a diagnosis of paraphilia, specifically coprophilia. While Nick describes wearing female clothes, it is not clear that this is related to sexual arousal as he described he specifically likes female clothes because they are "smooth and soft," and did not relate the activity to sexual arousal. While he has violent sexual fantasies and fantasizes about sexual activity with young girls, he denied that he has ever acted on these impulses.



Diagnosis



Axis I: 300.23 Social phobia

296.33 Major depression, recurrent, severe without psychotic features

302.9 Paraphilia not otherwise specified, coprophilia



Axis II: 301.22 schizotypal personality disorder



Axis III: none reported



Axis IV: Psychosocial stressors: problems with primary supports; occupational problems; other psychosocial and environmental problems



Axis V: Current GAF: 30

Highest GAF in the past year: 30



Recommendations



1. Nick is an individual who is suffering from several depressive symptoms that appear to be minimally responsive to medication and therapy at this time. In addition, Nick appears to have significant problems with cognitive distortions and his orientation to reality is tenuous. It is likely that his social isolation, which allows him to spend most of his day fantasizing, is contributing to his overall impairment. While Nick has not acted on any of his impulses, based on the level of specific violent details involved in his fantasies and his grossly impaired judgment, it is strongly recommended that Nick be referred to a partial hospitalization program where he can be supervised and treated on a daily basis. This type of environment will also be able to provide him with a safe environment with structure to work on decreasing his anxiety related to interpersonal contact. If Nick is unwilling to attend a partial hospitalization program, his status should be monitored frequently by his intensive case manager to determine if inpatient treatment may be necessary.



2. With regard to his violent sexual fantasies that involve both adults and minors, it is recommended that a comprehensive psycho-sexual evaluation be conducted as soon as possible. It is recommended that a residential treatment center be considered due to the violent nature of his thoughts.



3. With regard to his housing situation, Nick has questioned his ability to live independently. Presently, his judgment and decision making abilities are impaired and it is questionable whether he would be able to function appropriately if faced with an emergency in his home. Based on this, it is recommended that a residential program be considered.