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. B
iever
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 demon
strated social weaknesses may be related to cognitive defects, personality facto
rs, 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 s
upportive 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 a
nd 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 pare
nts are divorced; his mother is remarried and his father resides with his girlfr
iend. 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 t
o their house although Nick reported that he does not know what prompted that de
cision. 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 a
cknowledged 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 represe
ntative 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 pr
esent. He denied any past violence or inappropriate behavior towards her.

Nick lived with his biological parents until they divorced when he was a young c
hild. Nick reported that he does not recall much about his childhood, although h
is aunt reported that his father was alcoholic, abusive, and unpredictable. His
aunt could not recall any specific incidents. Nick remained living with his moth
er when his parents divorced and after his mother's second marriage. Nick was ho
meschooled for a period of a couple years in high school. His aunt, Joyce, was h
is primary instructor. After Nick completed high school, his aunt assisted him i
n applying for social security disability, helped him to get connected with a me
ntal 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 dis
tress and stated, "Why would these people even think I could live alone?" He rep
orted that he is fearful to leave his house or to answer his door. He acknowledg
ed that his decision-making skills are poor at this time. When asked what he wou
ld 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 f
ire because he did not think you could throw water on a stove, but at no point d
id he mention calling 911 or using a fire extinguisher.

In terms of family psychiatric history, his aunt reported that his maternal gran
dmother was diagnosed with dementia recently and may have previously been diagno
sed with bipolar disorder. Some extended cousins are reported to have been diagn
osed with bipolar disorder. Family substance abuse is significant in that Nick's
father was reportedly an alcoholic and according to Nick, his father also abuse
d 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 hav
e a religious affiliatio.

Developmental/Medical

Several attempts were made to reach his mother, Carol Osborne, to obtain develop
mental 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 delive
ry. 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 ent
ering kindergarten.

Medically, Nick reported that he does not have a primary care physician. He deni
ed any history of seizures, head trauma, unusual illness, or medical hospitaliza
tions. 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 d
ue to allergies. He is presently prescribed Viibryd for anxiety and depression a
nd 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 medicatio
n as prescribed and follows with Dr. Biever, his psychiatrist, on a regular basi
s.

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 destru
ctive to property. His aunt also recalled an incident where Nick's father spanke
d him at school and "somebody checked into that." Nick's parents divorced someti
me 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 basi
s. 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 indica
ted that he was placed in full-time emotional support in 4th grade, although a c
opy 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 pe
r 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 r
elationships which is demonstrated by his inappropriate behaviors to peers. Unti
l 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 fo
r 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 s

equencing, wide vocabulary skills, verbal reasoning skills, abstract reasoning a
bilities, academic abilities. His needs were described as increase compliance wi
th school rules/expectations, increase appropriate social interaction with peers
, specifically to lessen physical aggression toward peers, increase ability to s
eek help when needed and to develop strategies to deal with anxiety and withdraw
al.

There is no other school information available until he returned to Penn Manor H

igh 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 f
ull-time emotional support. Information from his IEP that year noted, "since enr
olling in Penn Manor School District as a junior, Nick has been doing very well
academically and behaviorally." Observations indicated that "his teachers descri
be Nick as quiet, intelligent, and funny. In class, Nick will sit quietly and ra
rely 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 t
o join. Nick sometimes makes comments or acts in ways that has a tendency to dra
w 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 re
turned to school as a junior, Nick reported that he spent most of his time sitti
ng 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 so
cial 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 re
lationship with his family members. He developed a relationship with some indivi
duals online when he was a teenager. One individual is "Anna" and she has blocke
d all contact with him, although he continues to make attempts to contact her el
ectronically. 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 Ca
lifornia, but stated that he has no plans to go to California to find her "becau
se 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 woul
dn't commit a major crime to reach her, but probably a misdemeanor." He continue
s to have frequent contact with a young woman, "Jessa," and Jessa's fianc, "Willia
m." Nick refers to Jessa as his mother, but reported that he does not really lik
e 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 gir
lfriend that he has met in person and he reported that the only girlfriend he ha
s 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, bu
t he does not currently have access to women's clothes. He reported that he freq
uently masturbates and that he feels his sex drive is "more active than most peo
ple." He enjoys pornography that involves feces and he reported that he frequent
ly fantasizes about having anal sex, consensually and forcibly with females. He
also reported that his sexual fantasies include young girls who "can talk in ful
l 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 reporte
dly unsuccessful. When this evaluator told him that this type of activity is ill
egal, he indicated that he did not understand why that would be.

Nick is not involved in any community activites and reportedly only leaves his a
partment 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 com
munity 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 re
ported 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 hist
ory 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 t
o 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, "An
na", 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 Gl

en Behavioral Hospital. He was involuntarily committed after he became physicall
y aggressive with his mother. A discharge summary from this facility indicated t
he following diagnoses: major depression, social phobia, avoidant personality tr
aits. It further stated that, "psychological testing was completed which support
s the above diagnoses, it did not support psychosis." During his hospitalization
, anti-depressant medication was recommended but "mother did not indicate that s
he 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 treat
ment. Nick reported that his mother does not believe in mental illness and, ther
efore, 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 appro
priately, although he was malodorous. He had a beard and his hair was slightly u
nkempt. Nick reported that he generally only showers once a week. His eye contac
t 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 an
d was able to engage in a reciprocal conversation. He answered all questions, at
times offering relevant spontaneous information. He was able to complete the en
tire evaluation in one day, taking a 20 minute break for lunch. After he complet
ed 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 organiz
ed, relevant, and goal-directed with content of thought focused on providing inf
ormation as requested and completing the tasks required. His responses were rele
vant to the questions. Nick did not exhibit any overt indications of an underlyi
ng 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 suicida
l 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 ideatio
n 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." H
e indicated that he frequently has "videos" playing in his mind that involve kil
ling 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 mo
ther in the past and has left bruises on her. When he was fifteen, he was psychi
atrically hospitalized after he assaulted his mother because she would not allow
him to use the computer. Nick denied any history of cruelty to animals, vandali
sm, 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." H
is insight was fair as he indicated that he has pursued therapy, psychiatric tre
atment, 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 wh
y 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 fe
male. Additionally, he showed this evaluator, as well as his therapist, conversa
tions 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 unu
sual.

Validity Considerations

The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) yielded an invalid pr

ofile based on Nick's endorsement of far more symptoms than would be typical eve
n 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 symp
toms in several domains, frequently and intensely, and that the symptoms are cau
sing a significant amount of stress and impairment.

Intellectual Functioning

The Wechsler Abbreviated Scale of Intelligence, 2nd Edition (WASI-II) administer

ed in order to assess Nick's cognitive functioning and to obtain and understandi
ng of his level of intellectual functioning. The WASI-II is designed as a screen
ing tool to quickly and accurately estimate an individual's intellectual functio
ning. Assessment of Nick's present level of cognitive abilities indicates overal
l intellectual functioning in the superior range (WASI-II IQ = 129). Nick's IQ p
laces 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 d
eveloped than his nonverbal skills, although his nonverbal abilties, as evidence
d by his performance on the Perceptual Reasoning Index, are solidly within the a
verage 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 f
ell well above the norm. This subtest assesses an individual's expressive vocabu
lary, verbal knowledge, and fund of information. His performance on the Similari
ties subtest was equally as strong as his performance on the Vocabulary subtest.
The Similarities subtest measures abstract verbal reasoning and conceptualizati
on. Nick's performance on the Block Design subtest was above the norm. This subt
est measures spatial visualization, visual-motor coordination, and abstract conc
eptualization. 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 excep
tion of "ethereal" which he slightly mispronounced. His performance on this subt
est 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 ran
ge (SS = 114) and corresponds to a 12.8 grade level.

Neuropsychological Functioning

In order to further measure Nick's executive functioning abilities and his highe
r level cognitive skills, various tests were administered to obtain a clearer pi
cture of his strengths and weaknesses in these areas. The Delis-Kaplan Exsecutiv
e Functioning System (D-KEFS) is a measure of high order cognitive, executive fu
nctioning. The subtests were designed to assess complex multifactorial domains o
f 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 conne
cting circles tasks, demonstrated average to above average abilities in cognitiv
e flexibility, a classic executive function that is essential for higher-level s
kills 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 divid
ed 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, w
ith a switching task also presented. Nick's ability to generate words starting w
ith a specific letter is slightly below what would be expected. He appeared to b
e anxious during this task and some of the words were associated with sexual act
ivity such as "fornication" and "syphilis." His ability to generate words that f
it into a specific category is slightly below the expected level; however, his a
bility to cognitive shift between categories is at the expected level with his a
ccuracy 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 pr
oblem solving abilities, Nick performed in the range above what would be expecte
d for an individual his age. His performance on this measure suggests that his a
bility 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 strateg
ies. The executive functions assesed include the perception of various categorie
s 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 cons
istent with his performance on all other measures of abstract thinking and probl
em solving, suggesting that these higher level thinking skills are very well dev
eloped in this young man.

The Proverb Test evaluates the abstract interpretation, understanding of word me

anings, 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 abil
ities 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 var
ious 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 c
asually described how he feels they deserve to die because they are very conserv
ative 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 h
e 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 con
sensual sex. His sexual fantasies involve feces as he reported that he becomes s
exually aroused by fantasizing about women defecating and that he has used feces
when he masturbates. He does frequently view pornographic tapes that involve th
e 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 touche
d each other and this was reported to be consensual. Nick shared his journals wi
th this evaluator which included numerous writings about sex and violence. He ha
d written about being angry with his aunt and described how he would like to ana
lly 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 someth

ing was falling from the sky and he thought it was semen, but later realized tha
t it was rain. On the MMPI-2, Nick's responses on the Schizophrenia scale were q
uite high (T = 112). Specifically, his high score on the social alienation subsc
ale (T = 105) suggests that he perceives that he is mistreated and misunderstood
. His emotional alienation score (T = 98) indicated that he has a significant am
ount of fears, depression, and apathy. Additionally, the high T scores on the La
ck of Ego Mastery, Cognitive (T = 90) and Conative (T = 92) scales are consisten
t with someone who fears losing control, feels as though life is unreal and like
ly responds to stress by retreating into a fantasy world. His responses on the T
hematic Apperception Test (TAT) suggested some problems with reality orientation
. He described one picture as a house in a snowstorm with "eyes" in the backgrou
nd "that's like a ghost or something." On another card, he saw a figure in the b
ackground 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 h
is impulses but attributed part of that to his fear to leave his home. He did st
ate 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 success
fully controlling his angry impulses.

Nick described a significant level of social anxiety, which he has experienced f

or several years. He reported that he did not want to go to school and that is w
hy he was homeschooled from 7th to 10th grade. When he did return to public scho
ol, he reported that his attendance was good, but he did not like to leave the c
lassroom. 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 afr
aid of everything, I feel like I can't defend myself and I don't know what I wou
ld do if someone broke in." He also reported that he does not like to take showe
rs 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 p
roblems making decisions, "I have trouble placing an order at McDonald's." Nick
was able to describe appropriate social behavior and described being socially av
oidant because he becomes so anxious around others that he cannot function or co
mmunicate. He indicated that he is aware that some of his anxiety resolves aroun
d 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 = 1
01) with responses that corresponded to a signigicant amount of persecutory idea
s (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 bro
ken at the neck; someone probably did it on purpose." Another card showed a litt
le boy sitting alone and he described the boy as "upset" and that "maybe his par
ents 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 "probabl
y the watch, they probably sleep in shifts."

With regard to his mood, Nick stated that he is generally depressed. He often fe
els hopeless, but indicated there are times when he is hopeful; mainly when he f
antasizes 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 sho
wers once per week with prompting and does not attend to his personal care consi

stently. 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 pr
esent suicidal ideation, but noted that he has had these thoughts in the past, b
ut 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 depr
ession, psychomotor retardation, physical symptoms, mental dullness, and broodin
g. 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 functionin
g 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 signifi
cantly more developed than his nonverbal skills; which is sometimes the case in
individuals with Asperger's disorder; however, Nick does not demonstrate any def
iciencies in academic achievement as if often co-morbid in inidividuals with Asp
erger's disorder, nor does he show any deficits in his higher level thinking ski
lls. Quite the contrary, Nick demonstrated well developed abstract thinking, pro
blem solving, cognitive flexibility, and the ability to sustain divided attentio
n. 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 consider
ation of a diagnosis of Asperger's disorder and reported his problems with socia
lization to be primarily related to his social avoidance and social phobic behav
iors. Presently, Nick demonstrates a marked fear of all social situations becaus
e he feels he does not know how to communicate and behave in these situations. W
hen he is required to attend certain places, such as the grocery store, he repor
ted 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 mor
e 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 evide

nced by his extreme discomfort with social interactions and his inability to dev
elop close relationships. In addition, he also has cognitive distortions. He bel
ieves 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 re
fusal 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 rel
ationships 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 a
dvice. He demonstrates obsessive ruminations with explicit sexual and aggressive
content and does not seem to understand that this is atypical, especially his f

ocus on discussing his intense dislike for vaginas. His speech, although well de
veloped, can be circumstantial and odd as when he described young girls as "bein
g house-trained and able to speak in complete sentences." His affect is constric
ted and he demonstrates little to no emotion, he lacks close friends, and his so
cial anxiety is pervasive and seems to be more associated with fears of being ha
rmed 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 co
llateral information, these behaviors have been longstanding and likely represen
t 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 prima
rily 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 t
hat 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 perf
ormance on tests of higher level thinking skills indicated that his abstract rea
soning, problem solving skills, and cognitive flexibility are very well develope
d, which is not typical. His problems with socialization appear to be more relat
ed to social anxiety and fears, rather than an inability to understand social cu
es or a lack of understanding about appropriate social behavior.

Nick has previously been diagnosed with major depression and he clearly meets cr
iteria for this disorder at this time. He described that he has a pervasive depr
essed mood and finds little enjoyment in any activities. His functioning in all
domains is impaired and he has great difficulty making simple decisions. His sel
f-care is marginal, although he understands what activities of daily living shou
ld 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 mo
tivation and energy. It appears that he has had several episodes of depression s
ince 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 Ni
ck describes wearing female clothes, it is not clear that this is related to sex
ual arousal as he described he specifically likes female clothes because they ar
e "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 gi
rls, 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 pr

oblems; 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 add
ition, Nick appears to have significant problems with cognitive distortions and
his orientation to reality is tenuous. It is likely that his social isolation, w
hich allows him to spend most of his day fantasizing, is contributing to his ove
rall impairment. While Nick has not acted on any of his impulses, based on the l
evel of specific violent details involved in his fantasies and his grossly impai
red judgment, it is strongly recommended that Nick be referred to a partial hosp
italization program where he can be supervised and treated on a daily basis. Thi
s type of environment will also be able to provide him with a safe environment w
ith structure to work on decreasing his anxiety related to interpersonal contact
. If Nick is unwilling to attend a partial hospitalization program, his status s
hould be monitored frequently by his intensive case manager to determine if inpa
tient treatment may be necessary.

2. With regard to his violent sexual fantasies that involve both adults and mino
rs, it is recommended that a comprehensive psycho-sexual evaluation be conducted
as soon as possible. It is recommended that a residential treatment center be c
onsidered 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 impair
ed 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 res
idential program be considered.