The patient has a long history of depression and fatigue with initial diagnosis of depression going back to as early as the 1950's. In the early 1960's the patient moved to New York to enter into psychoanalysis 2 days a week. After 3-4 years in psychoanalysis, he experienced relief from his depression and had the energy to pursue his [stock] broker license, As a result of fatigue and depression, however, the patient has had extended periods of time unemployed, but he has maintained his ability to live independently as regards to his instrumental activities of daily living (e.g., money management, pill taking, etc.).

In the late 1960's, the patient's depression returned and he developed fatigue. In 1969 he started to become more and more fatigued and began taking aspirin for co-occurring pain. In 1973, he developed hyperalgesia to water; he noticed painful muscle tension after taking a shower. By 1974, his fatigue became disabling to the point that he [spent] most of his time in bed. Over the years, his post-shower symptoms also developed into fatigue, lasting about 5 days; as a result, currently, he showers about once a week and taking a "bird bath" other days. After receiving supplemental magnesium injections for a deficiency, he experienced roughly two, as opposed to five, days of post-shower fatigue. Unfortunately, the benefit of the magnesium injections waned and symptom duration resumed. Dermatographia was reportedly diagnosed in 1998.

Since initial diagnosis of depression, the patient has reported variable benefits from treatments which have included a number of medication trials, psychoanalysis, psychotherapy, and in 2004, 22 sessions of electroconvulsive therapy (ECT). He denied currently being depressed but reported recalcitrant fatigue. He also complained of memory difficulties subsequent to the ECT, [The patient remains on a cocktail of antidepressants.]

A neurological exam on 427/04 was conducted in order to evaluate "an internal vibration," intracellular hypomagnesaemia, and cerebral atrophy on brain scanning. A very low amplitude, fast frequency action tremor was identified in his hands bilaterally, which was presumed to explain the sensation of an internal vibration.

A CT of the head September 8, 2008 revealed mild prominence of the extra axial spaces at the convexities, right greater than left. No mass effect was seen. No significant atrophy was seen. Slight asymmetry of mildly prominent extra axial spaces at the convexities, right greater than left, was interpreted as possibly reflecting resolution of a small subdural hematoma or hygroma, possibly due to mild trauma or coagulopathy.

The patient lives alone. His father, who died in his mid-70s from cancer, had some college before going into the family infant clothing manufacturing business. the patient's 92-year-old mother is reportedly in good health; she completed some college and was a homemaker. The patient's younger brother, Rick took over the family business; he is 66 years-old and has high cholesterol, which is reportedly controlled.

The patient has a maternal aunt, who at 84 years of age, died of colon cancer. She had also received ECT to treat depression. Family history was otherwise positive for cancer (father), hyperlipidemia, and stroke (paternal grandfather). Additional neurological, psychiatric, and developmental disorders were denied.

The patient was reportedly the product of normal pregnancy and delivery, achieving his developmental milestones on time. Childhood medical history was significant for two losses of consciousness (LOC). At 5 years of age, he was hit by a car and transported by ambulance to the hospital, where he woke up. His mother estimated the LOC was between 40 and 60 minutes. The hospitalization lasted several weeks because of a broken leg and ruptured spleen. Subsequent difficulties learning to read or write in school were denied. A second brief LOC followed his falling off a slide at school in elementary school. No sequelae were noted.

Additional falls, blows to the head, seizures, or black outs were denied. Adult medical history was significant for mental health hospitalizations; the patient reported a five week-long hospitalization while he was changing medications (i.e., not for a psychotic episode). He has also been in therapy off and on for several years. He has been aware of his hand tremor for years, attributing it to side-effects of medication, although this has not been medically verified. The patient smoke[d] a pack of cigarettes a day for 10 years, quitting in 1969. He denied a significant history of drinking alcohol or drug use.

He started pre-kindergarten at 4 years of age; he denied any behavioral problems, and experienced no difficulty learning reading or math. He played the clarinet and was in the orchestra; he described himself as a mediocre student whose favorite subjects were math and science. He attended some college and also earned his stock brokers license.

Following college, he was given a sales position in the family business. However, by all accounts, he did not have much success in this position. Later he went on to earn his broker's license, and worked in financial firms, before finally obtaining an administrative position at Bear Stearns.

After working for Bear Stearns for a few years, he reported being "totally burned out." He was fired from his position with Bear, Stearns, which he said, saved his life. However, while there, he had become enamored of a woman. He was unemployed for about 18 months, during which time a restraining order was filed against him by the woman he was interested in. Her lawyer eventually asked him to leave the area, and he decided to move to San Francisco. Although not initially intending to stay, once here, he decided to get a job as a night desk clerk in Little Italy and became a resident.

Since living in San Francisco, he has held a variety of odd jobs, working most frequently as a security guard or a clerk, and in computer (IT) support. He retired in 2002.

He was born and raised in Chicago but moved to New York in his early adulthood. Currently, he is financially supported by Social Security and monies from his family. He lives alone, receiving no supportive services, and independently shops, manages his finances, pill taking, and medical appointments

He never married, but does date. He indicated he would like to have a more interesting social life, indicating that when he was young and in good health, he had a better social life. His social life declined after developing depression and fatigue.

In addition to his volunteer service, he currently takes dancing lessons for socialization and exercise. He commented that he is shy in groups, has difficulty starting conversations, and has a difficult time taking criticism. He also sees a massage therapist for the physical contact. he also reads CPU magazine to keep up with his computer skills, as well as Scientific American and the New York Times.

In addition to the clinical interview, tests administered include the following: Adult Daily Living Questionnaire (ADLQ); Beck Anxiety Inventory (BAI); Beck Depression Inventory - II (BDI-II); California Verbal Learning Test - II(CVLT-II); Delis Kaplan Executive Function Systems (DKEFS) selected subtests: Trail Making Test, Verbal Fluency, Design Fluency, Color Word Interference, and Tower; Judgment of Line Orientation; Minnesota Multiphasic Personality Inventory - II Revised Form (MMPI-II RF); Taylor Alternative Figure Test; Test of Memory Malingering (TOMM); Wechsler Memory Scale (WMS-III) Faces I & II; Wide Range Memory and Learning 2nd edition (WRAML-2); and Wisconsin Card Sorting Test (WCST). Tests were administered by [... and ...]. Raw data will be made available to an authorized licensed psychologist upon request.

Percentiles are rankings that compare his performance to others in his age group. Performance levels are generally classified as follows.

He initially presented as a pleasant man who was well-groomed but unshaven. He explained that he was too tired to shave and he napped much of the morning.

He appeared largely interested in the testing. Occasionally, he complained about tasks he found challenging. For example after being presented with a list of words to remember, he said, "you've got to be kidding!: He also said he "hated" a story memory task. When asked to produce a drawing from memory, he gave a look of disdainful astonishment on his face, which was quickly alleviated by a humorous comment, to which he laughed with a broad smile. On the other hand, he was also somewhat provocative, as he used expletives in the face of challenges, a number of occasions, even when he was able to answer the items correctly.

He often laughed during the assessment at appropriate times. Eye contact was social, and his facial expression was full range and appropriate to content. Mood was within normal limits. Speech was fluent. Rate and rhythm were normal. Volume was audible and intelligible, tut his voice was hoarse. Thought content was logical and coherent.

He obtained scores indicative of good effort (TOMM=50/50) on embedded effort tests, and he demonstrated engaged behavior throughout testing. Thus, the present evaluation is likely a valid reflection of his current level of neuropsychological functioning.

He was administered selected subtests from the Wechsler Adults Intelligence Scale, Third Edition (WAIS-III). His estimated general intellectual functioning was in the high average range (110; 75th percentile).

His speed of processing was high average (82nd percentile), which is entirely different from the findings of [his previous] evaluation, suggesting a situational reason at that time. His ability to hold information in mind and manipulate it in order to solve problems was average (66th percentile), as it was when Dr. [...] evaluated him. Pre-morbid intellectual functioning was estimated to be superior (123=94th percentile), above what would be expected given his educational and occupational attainment, and similar to the results of "hold" tests Dr. [...] administered

Adequate for simple material.

Ability to recall a randomized orally presented number string was average (5 digits forward; 5 digits backwards; 50th percentile). He also was average when asked to mentally hold and order and to manipulate a string of randomly presented numbers and letters (LNS=63rd percentile). When context was provided to orally presented problems, and he was asked to compute arithmetic problems mentally, he was high average (75th percentile). Visual attention was average (Picture Completion = 37th percentile).

Average or above.

His best performance was on a task of confrontation naming (93rd percentile), which was superior, contraindicating an organic basis for word finding difficulties. When patients complain of word finding difficulties in their everyday lives but do well on testing, this usually is a product of divided attention or being distracted while trying to come up with a particular word.

On a test of abstract reasoning his performance was high average (similarities = 84th percentile). Verbal fluency was average for use of both semantic and phonemic cues (respectively, 50th percentile and 50th percentile). Word reading was average for both speed (50th percentile) and accuracy (>99th percentile), while naming color patches was average for speed (37th percentile) with two uncorrected errors (5th percentile), consistent with difficulties with tracking his own performance and self-monitoring.

High average.

Some difficulties do to inattentiveness were seen in the context of average learning and retention.

Verbal Memory. His verbal memory for stories was average (63rd percentile). His ability to recall conversations was assessed by asking him to repeat back stories read aloud. Recall was normal (63rd percentile), but recognition was at the low end of average (25th percentile), which is usually due to inattentiveness.>/p>

On a list learning task his acquisition was high average (88th percentile). His learning slope was high average 84th percentile). Delayed recall and retention were both average (30th percentile and 50th percentile, respectively). He used a serial strategy for remembering words instead of more deeply encoding the words with a semantic strategy (16th percentile) indicating poor tracking and intrusions were also very high on delayed recall (<1st percentile). Finally, after the administration of a second distracter word list he was challenged in discriminating first list words, suggesting problems with source memory.

Visual Memory. Memory for pictures was high average (84th percentile) and recognition of pictures after a delay was high average (75th percentile). Delayed reproduction of a complex geometric figure was superior (95th percentile). Thus, basic and complex visual memory is adequate. Nevertheless, recognition was impaired (1st percentile), which is typically associated with reduced attention.

Face memory was superior immediately (95th percentile), indicating no specific deficit of facial processing. However, after a 30-minute delay, his recognition was low average (16th percentile), leaving open the possibility of either poor facial memory versus difficulties with attention observed across other delayed recognition tests.

Average or above, except for verbal multi-tasking.

Sequencing letters and numbers was average (50th and 63rd percentile, respectively), as was motor speed (64rd percentile). His ability to maintain set was average (30th percentile). Switching between sequences, a form of mental multitasking, was also average for both speed (50th percentile) and accuracy (30th percentile).

Non-verbal fluency was average (50th percentile) as was set-switching on the same task (63rd percentile). However, while verbal fluency was average (50th percentile), when he was asked to switch between two categories, his fluency was below expectations (9th percentile). Thus, it appears that there is more difficulty for him in switching set when the task accesses language domain of executive functioning compared to asking him to switch set when the material is non-verbal.

On a test of problem solving that required planning, he was very superior (Tower - 95th percentile). When switching sets between task instructions, his performance was average (63rd percentile). However, he had difficulty maintaining set on a problem solving task that required hypothesis testing and set switching (Loss of set=3; 6th-10th percentile), Nevertheless, he was able to problem solve adequately (categories=4; 32nd-42nd percentile).

He made more repetition errors than expected (3rd percentile) indicating poor tracking, and intrusions were also very high on delayed verbal recall (<1st percentile) as described above. Fianlly, there was evidence of problems with source memory on a word list.

He is a 69 year-old, Caucasian man with a history of depressed mood with irritability and persistent intractable fatigue symptoms accompanied by muscle tension and pain. Onset of his reported pain symptoms began as early as 19. A CT of the head revealed some mild atrophy of the convexities, right greater than left.

Results of the present evaluation were largely normal, with high average intellectual functioning currently, no word-finding difficulties, and average or better memory of both visual and verbal material. This reflects improvement over his performance with Dr. [...]. There was no consistent pattern of visuospatial deficits that might be expected as the clinical correlate of right-hemisphere atrophy. However, there was evidence of some challenges with executive functioning for divided attention, multi-tasking, tracking, and self-monitoring, all of which are higher order forms of complex attention. This problem was inconsistent, but resulted in performance that was borderline impaired, which is significantly below expectations for someone with overall high average abilities across other domains.

Challenges with divided attention, multi-tasking, tracking, and self-monitoring are generally localized to the frontal regions. His challenges, though, were relatively subtle in that he did not show this problem across all similar tasks. Rather, his attention appeared to wax and wane. This is more consistent with fatigue. Moreover, it is not uncommon for people to experience and describe problems with complex attention as memory problems.

Current diagnoses include fatigue and depression. However, on the present evaluation, he did not endorse significant levels of depression or anxiety. he did describe sleeping with the television on all night, which likely interferes with memory consolidation, but he indicated feeling well rested in the morning. Moreover, as it happened, his television was broken during the present evaluation, and therefore, that issue could not explain the subtle difficulties observed on the present evaluation with divided attention, multi-tasking, tracking, and self-monitoring. [While my television was broken, my radio was not. It was on all night.]

He listed symptoms that are suspicious for Chronic Fatigue Syndrome (CFS) or fibromyalgia including fatigue unaffected by rest, longer than three months of persistent muscle and joint pain, memory, and cognitive problems. Although these problems and his fatigue have not impacted his ability to manage his finances, do his shopping, adhere to his medication regimen, work as a webmaster, or affect his other instrumental activities of daily living, they do limit his ability to enjoy his free time and to socialize in evenings. Thus, a referral for evaluation of these syndromes is recommended, taking into consideration that he has been experiencing these symptoms for much of his life. Moreover, the fact that he is medicated for depression with Cymbalta, an SNRI, should also be considered during his work up for CFA and/or fibromyalgia, since SNRIs have benefit for patients who have been diagnosed with fibromyalgia.(1)

Deferred.

He has subtle difficulties with executive functions that do not meet criteria for Mild Neurocognitive Disorder.

1. Additional diagnostic testing: Rheumatologist to assess for fibromyalgia and chronic fatigue syndrome and to discuss possible treatments including medications like milnacipran(1).

2. If additional diagnostic testing does not yield a diagnosis, an MRI of the brain may provide further relevant information.

3. In order to address his subtle difficulties with complex attention, he would benefit from attempting to engage in just one task at a time. He may also benefit from computer programs such as those produced by Lumosity.com or by Posit Science (Brain Fitness Program).

4. He would likely benefit from improved sleep hygiene practices as well as increased socialization.

TOMM;

Trial 1:=50/50; Trial 2:=50/50