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RALEIGH DISABILITY DETERMINATION SERVICES PSYCHOLOGICAL EVALUATION CLAIMANT: DOE, JONATHAN CLAIMANT#: 156332 DATE SEEN: 10/12/2010 EXAMINER: Dr. Ken Smith 100 Main Street Cary, North Carolina 27518 ADJUDICATOR: CLARK MILLER ARRIVAL INFORMATION:
The claimant arrived early for his scheduled appointment at 10:00 AM on Tuesday, October 12, 2010.
Jonathan arrived for the appointment by bus. The claimant does not have a driver's license. Jonathan
showed the examiner his North Carolina photo I.D. card. He stated he has never had a driver license in
the past. Jonathan's group home manager was supposed to accompany the claimant on his bus trip to
the office, but a last minute scheduling change forced Jonathan to get on the bus alone today. Given the
claimant's poor performance and unstable presentation during the interview, the examiner accompanied
the claimant out of the office at the end of the session. Assistance was provided in crossing the street
and helping the claimant get on the city bus. The bus driver was alerted that this man may need
assistance in getting off at his destination. The claimant was unable to provide an estimate of travel to
reach the office today. The claimant was given total assistance by office staff in completing the
computerized intake process. Jonathan stated that he does not know how to use computers. Although
he has access to a computer in the group home where he resides, he has never used the system.
Jonathan is a 28 year-old Caucasian male. He was 5 feet, 10 inches tall and weighed 185 pounds. Hisweight has reportedly remained stable over the past year. The claimant ambulated very slowly in theoffice today with a very unsteady gait. He did not require a cane or walker. Jonathan stated that he iscapable of walking, but he added "Some of the medications I take make me really sleepy." The claimantwas adequately dressed in casual clothing appropriate for the season. Jonathan was marginallygroomed. His fingernails were noted to be soiled and his hair appeared unkempt underneath his sweat- stained baseball cap. Jonathan said that if he doesn't take his medications for anxiety, he will begin totwitch "a little bit." If he doesn't take his seizure medications, he will have uncontrolled movements withhis seizure activity.
HISTORY OF ILLNESS:
Included with the file for this claimant was the following background document:
(1) SSA Document: Completed by Jonathan Doe, claimant (with assistance), (undateddocument). Jonathan was claiming disability due to anxiety (with chest pains), seizures, andbipolar disorder. Jonathan had worked briefly as a janitor in 2005, but he was fired from thisjob. He said this was his only job in the past 12 years. The claimant had obtainedmedications from a community mental health center in recent years. Medications included Dilantin, Ferrous Sulfate, Metoprolol, and Prozac.
When asked to describe his current problem or condition Jonathan stated, "My seizures. I can't workbecause I might have a seizure while working." Oddly, Jonathan said that he had been working as ajanitor in the past, even though he was apparently affected by his seizure disorder at the time of hisemployment. He complained that he used to get his "checks" for disability in the past, but he reportedthat no payments had been received recently. Jonathan was fearful that his mother may have beenreceiving his previous disability payments. The claimant's older brother reportedly had been receivingdisability benefits, and there were concerns expressed about his mother also keeping these payments forherself. Jonathan said that both he and his brother had their mother as the payee, but his brotherrecently became a direct payee. When asked about past mental health treatment, Jonathan said that asa teenager, he had been seeing a therapist. Jonathan said he was currently receiving treatment atCentral Raleigh Adult Mental Health Services. He saw his psychiatrist at this facility earlier this week. Jonathan denied any current alcohol or illicit drug use. "This stuff isn't allowed at the group home,"added the claimant.
November 05, 2010 CLAIMANT: 156332 Doe, Jonathan (Continued)
The following medical history was provided from the claimant intake forms: TREATMENT RECEIVED Seizures, hit in head with a frying pan and thrown through the wall Bipolar diagnsosis Medication and counseling Hospitalized, counseling, and medications The following information about current prescription medications was provided from the claimant intakeforms: Dilantin prescribed by Dr. Bartron for seizures Feldene prescribed by Dr. Bartron for pain and inflamation Metaprolol prescribed by Dr. Bartron for high blood pressure Oxycodone prescribed by Dr. Richland for pain Prednisone prescribed by Dr. Bartron for inflammation Jonathan has had horrible pain in his head for two to four years. The pain occurs daily so the claimanttakes medicine often plus reduces pain by heat treatment and lying down. The claimant has tonic-clonic(grand mal) seizures. The seizures started in 1995 but are treated with medication. His last seizure wasearlier this week.
Substances reportedly used by the claimant in the past included caffeine, tobacco, alcohol, marijuana,and tranquilizers. Substances still being used reportedly include caffeine and tobacco. He has not been in any alcohol treatment program in the past year. He has not participated in alcohol self-help groups inthe past. He has not been in a drug rehab program in the past year.
PERSONAL AND FAMILY HISTORY:
Jonathan was born on October 30, 1981 in Boone, North Carolina. His birth father was George Doe, an
auto mechanic. His birth mother was Rita Doe, a food server. His family included two brothers and three
sisters. Jonathan was the third child in the family. The family moved frequently while he was growing up.
The claimant indicated that he has not completed high school, with progress made through the tenth
grade. Jonathan attended all special ed classes in school. He described himself as a poor student. The
claimant was active in the following extra curricular activities while attending school: worker in lunchroom.
He identified his primary occupation as a janitor for less than a month. The claimant was very uncertain about his employment history. His background information indicated that he had worked as a janitorabout four or five years ago. He thought he had been been fired from the job for getting angry at anotheremployee. When asked about plans to work in the future, Jonathan indicated "No." The claimant reportedthat he could not work at all. The claimant is not applying for work. He does not plan to return to work.
The claimant made the following comment: "I would have a hard time following directions." Jonathan provided the following information about prior work experience: Janitor at Thomas Case High School, but later fired The claimant reported that he has lived in the area for four years. He lives in a group home withroommate of the same sex. Jonathan said that his sources of support include welfare, food stamps, andblood plasma sales.
Jonathan provided the following relationship history: November 05, 2010 CLAIMANT: 156332 Doe, Jonathan (Continued)
RELATIONSHIP CHANGE Moved in with girlfriend Broke up with girlfriend Claimant indicated he is not in trouble with the law now. The claimant has spent time in jail and made thefollowing statement concerning offenses: Loitering and trespassing, spent three days in jail beforecharges were dismissed.
ACTIVITIES OF DAILY LIVING:
Jonathan reported that he gets up each morning at 8:00 AM. The claimant stated that his morning is
spent doing the following activities: eating something and watching television. At lunchtime Jonathan said
"I eat and watch TV." Afternoon activities include: drawing pictures, working on jigsaw puzzles, and
watching TV. Jonathan's usual evening activities include: eating, taking a shower, watching TV, and
getting ready for bed. The claimant goes to bed at between 9:30 and 10:30 PM. Jonathan described the
quality of his sleep in the following manner: "I do not sleep well and I have bad anxiety."
The claimant provided the following information regarding specific activities he can or cannot perform.
Social activities included talking to friends and neighbors fairly often and using the phone to call familyand friends. Recreational activities included walking, watching TV, and listening to music. When theclaimant goes out someone else drives him or he rides the bus. The claimant cannot go shopping at all.
Jonathan cannot make his own shopping list. The claimant cannot pay the right amount and countchange. He doesn't have a checkbook. The claimant has someone to help him handle money. He canbathe himself in a tub or shower. He can dress himself and take care of his hair. He can take care of hisclothing.
The claimant claimed that he cannot concentrate on a task until it is finished. He reported that he cannotunderstand and remember what he reads or sees on TV. Things reported to be of interest include: conversation, enjoying friends, and making money by Welfare.
MENTAL STATUS EXAMINATION:
Mood was variable and unstable. Affect was labile. In describing himself, Jonathan said, "I am trying to
be a better person." Walking movements were very slow and deliberate. Unusual hand movements
were also observed during administration of the WAIS-IV.
Interaction style was distant. Speech quality was strained. Speech pronunciation was affected bystammering. Concerning organization of language, the claimant showed a diminished level ofexpressiveness. The claimant was reporting no auditory or visual hallucinations at this time. During theassessment, Jonathan did not appear to be responding to any internal stimuli. A history of suicide orharm to others was indicated by the claimant. Jonathan stated that when he was younger, he used to cut on himself. He said that his cutting continued for about a year. He stopped when he met a youngwoman who befriended him and became his girlfriend for a short period of time. Current suicidal orhomicidal ideation was denied.
In examining cognitive functions, Jonathan attained the following results: The claimant was oriented to person and place, but not time and purpose of visit to office.
(Digits Forward) 4/16, 0 errors through 2 digits1 error at 3 & 4 digits2 errors at 5 digits (Digits Backward) 1/14, No results with 0 errors1 error at 2 digits2 errors at 3 digits November 05, 2010 CLAIMANT: 156332 Doe, Jonathan (Continued)
Scaled Score: 2 (Extremely Poor) Serial 3's - The claimant made the following calculations: 17, 12(error), 8(error), 6(error). The claimantcomplained that the task was "too hard." The claimant was asked to perform the following mental calculations: 4+8="12(slowly used his fingers)";13+19="42(error, slow)"; 6x7="I have no clue." Alphanumeric counting produced the following responses: a1, b2, very slow, c3, d4, f5(error), g6, h7, i8,struggled in his responding, j9, "I feel like such an idiot", began to cry. He said he was crying because "Idon't know anything and I think that people make fun of me." The trial was halted by the examiner.
Short-term memory was judged to be marginal. The claimant was able to remember the examiner'sname. In recall of other items that were presented he could recall only one item freely out of five. Theclaimant recalled two items with prompting. Delayed memory was marginal. The claimant again recalledthe examiner's name. In recall of other items that were presented he could recall only two items freely outof five. The claimant recalled one item with prompting. Immediate memory was judged to be extremelypoor based on digit span trials. Fund of general information was poor. Awareness of current events waspoor.
A sampling of the claimant's vocabulary indicated that Jonathan understood the meaning of some simplewords such as "wheel" but not "recover." He was able to define words of slightly greater complexity suchas "inhale" but not "contemplate." He was unable to define more complex words such as "aversion" or"perjury." Abstract reasoning was found to be poor. Jonathan could describe the similarities betweenfairly concrete items, such as, appetizer and dessert, but he was unable to interpret even basic proverbs,such as, the early bird catches the worm. Poor judgment was demonstrated on a variety ofcomprehension probes. As an example, when asked, "What would you do if you had a leaky faucet?"Jonathan was unable to provide a commonsense solution for fixing the leak. He was unable to explain how credit cards might cause problems for people.
When asked to draw various geometric shapes, Jonathan was able to make appropriate discriminationsbetween simple shapes, such as a circle, square, triangle, and cross. Discriminations between simplefigure sizes (dime compared to a quarter, larger versus smaller) were not difficult for this claimant. Hehad no difficulty in drawing slightly more complex and abstract shapes, such as a stop sign. Jonathanwas unable to copy intersecting geometric figures as presented by the examiner. The claimant failed tocorrectly draw the face of a clock with hour and minute hands positioned at 20 minutes to 10:00 o'clockas directed. Jonathan was not able to demonstrate adequate ability in completing a multiple-step taskinvolving drawing appropriate parallel lines across the page. Line quality for this claimant was rathercrude, with unsteady movement and poor figure closure. Spelling was accurate for the words stop and cross, but the word square was misspelled as "sqare" and triangle was incorrectly spelled as "trangle".
PSYCHOMETRIC TEST RESULTS:
WECHSLER ADULT INTELLIGENCE SCALE - FOURTH EDITION On this administration of the WAIS-IV, Jonathan obtained the following composite scores: Perceptual Reasoning: Processing Speed: November 05, 2010 CLAIMANT: 156332 Doe, Jonathan (Continued)
Full Scale I.Q. Score: The following sub-test (**supplemental) scaled scores were obtained: VERBAL COMPREHENSION PERCEPTUAL REASONING Matrix Reasoning: **Figure Weights: **Picture Completion: Jonathan was very whiny and lethargic throughout today's administration of the WAIS-IV. He was oftenvery slow to respond and would easily give up, saying "I can't do that." Jonathan appeared emotionallyfragile and was easily distressed. During the Visual Puzzles sub-test, Jonathan's right hand was observed to be shaking, but the movements seemed more intentional rather than involuntary. Based upthe claimant's Full Scale I.Q. score of 52, Jonathan was found to be functioning in the low end of the MildMental Retardation range of intellectual ability.
On this administration of the Bender-Gestalt, the claimant performance was as follows: The claimant's drawings were placed on the page in a disorganized manner. Figure size was variableand use of space on the sheet was constricted. Line quality was poor, with excessive movement and poor figure construction. Frequently, Jonathan would complain that the figure was too hard to draw. Hewas encouraged to keep trying. The protocol was significant for Simplification, Retrogression, ClosureDifficulty, Motor Incoordination, and Impotence. Such findings were consistent with the claimant's lowlevel of functioning as found on formal ability testing.
FUNCTIONAL ASSESSMENT - ADULT:
A. ASSESSMENT OF ABILITY TO UNDERSTAND, REMEMBER, AND CARRY OUT AN EXTENSIVE
VARIETY OF COMPLEX INSTRUCTIONS.
The claimant would have difficulty in carrying out tasks at this level of complexity due to deficits incognitive functioning. Evidence supporting this opinion was found in the following assessment results:WAIS-IV findings of 52 Full Scale I.Q. (low end of Mild Mental Retardation range), difficulties on BenderGestalt consistent with low functioning, special education involvement throughout school, and extremelylimited employment history. In addition, there are other specific limitations in Jonathan's ability toconsistently sustain performance at this level. The claimant has a seizure disorder along with a history of November 05, 2010 CLAIMANT: 156332 Doe, Jonathan (Continued)
psychiatric symptoms requiring mental health treatment.
B. ASSESSMENT OF ABILITY TO UNDERSTAND, REMEMBER, AND CARRY OUT DETAILED At this level, the claimant's diminished functional capacity would still interfere with his ability to carry outdetailed tasks. C. ASSESSMENT OF ABILITY TO UNDERSTAND, REMEMBER, AND CARRY OUT SIMPLE ONE OR Given his presentation, Jonathan would have difficulty in carrying out simple tasks in a reliable andsustained manner. This claimant's only prior work experience had been as a janitor, but he was firedfrom this job after a brief tenure. His presentation today was also diminished by slow movement andunstable gait. He takes medications which seem to interfere with his motor control. D. APPROPRIATE INTERACTION WITH SUPERVISORS, CO-WORKERS, AND THE PUBLIC.
Jonathan presented today as a very immature and whiny young man. His mood was highly labile and heappeared to have low self-esteem. His low level of functioning would make him vulnerable tomanipulation by others. In his last and only job, the claimant was apparently fired due to fighting withother staff. Jonathan would have difficulty in his interactions with supervisors, co-workers, and especiallythe public.
E. ASSESSMENT OF ABILITY TO MAINTAIN CONCENTRATION AND ATTENTION SUFFICIENT TO CARRY OUT SPECIFIED TASKS.
The claimant was found to be low functioning and he exhibited consistent evidence of limitedconcentration throughout today's assessment. Jonathan was judged to have inadequate focus even on simple tasks. He would have difficulty in sustained performance and pace over the course of a typicalwork day.
296.80 Bipolar Disorder NOS Per History 300.00 Anxiety Disorder NOS Per History 307.89 Pain Disorder Associated With Both Psychological Factors and a GeneralMedical Condition 317 Mild Mental Retardation Low End of Range Claimant report of seizure disorder, high blood pressure, and pain (withmedications for treatment) Problems related to the social environment, Educational problems, Occupationalproblems, Economic problems, Other psychosocial and environmental problems Current GAF: 45 (lower with medical concerns)Highest GAF Past Year: 45 (lower with medical concerns) PROGNOSIS:
The prognosis for this claimant would appear to be rather poor. He was found to be very low functioning
throughout today's assessment. A notable concern for this claimant's performance was the role of his
medications. He indicated that his anti-seizure medications affected his performance, but with an
appropriate dosage, the anti-seizure medication would not typically result in such diminished
performance. Jonathan came in with paperwork showing he also has prescriptions for Oxycodone. The
November 05, 2010

CLAIMANT: 156332 Doe, Jonathan (Continued)
effects of Oxycodone would be more consistent with the sluggish responding reflected during today'sassessment. It is recommended that this claimant be referred to an appropriate medical specialist tofurther determine the degree of disability associated with his physical symptoms and medications.
MONEY COMPETENCE:
The claimant was found to be very low functioning and he will require assistance in the management of
his personal finances, including any monetary benefits awarded to him. In the past, issues reportedly
arose with Jonathan's mother as the payee. An independent, third-party should be used for managing
Jonathan's monetary benefits.
Dr. Ken Smith000001 November 05, 2010

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