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Friday, April 22, 2022
Sunday, April 08, 2012
NEUROBEHAVIORAL TOXICOLOGICAL ANALYSIS OF A RAMPAGE KILLER
Raymond Singer, Ph.D.
Independent Practice
Santa Fe, New Mexico
and
New York, New York
www.neurotox.com
ray.singer@gmail.com
and
Jack Dwayne Thrasher, Ph.D.
Independent Practice
Citrus Grove, California
Published until April 15, 2012 at: http://neurotox.blogspot.com/
Abstract
In September 2008, a 28-year-old man went on a shooting rampage that left six people dead and four others wounded. Upon arraignment, he told the judge that God told him to kill. The evaluation was conducted to determine if exposure to various neurotoxic agents impacted the defendant's sanity.
Methods: Review of records (criminal, educational, historical, medical, toxicological), diagnostic neuro-psychological interview, family members interview, police reports, and administration of neuropsychological/ behavioral tests.
Results: The defendant had a history of exposure to multiple neurotoxic substances. He lived in a new formaldehyde emitting mobile home from birth to age 14 with psychomotor symptoms. In 2001-2007, he worked as a union painter with resulting headaches and other symptoms. By 2003, there were reports of hallucinations. From 2006-2008, he lived in an extremely moldy trailer. Sampling of the trailer in 2009 found numerous ERMI moldiness index samples were at Level 4, showing the greatest likelihood of having a mold problem; mold and mycotoxin samples found 30.5 ppb trichothecenes; 57 ng/sample LSD from ergotomines in the ceiling, 86 ng on bed pillow; 28.9 ppb ochratoxin A on mattress cover; 14 ppb ochratoxin A in the defendant's urine. In April 2008, he had overdosed dermal exposure to pyrethroids for treating probably hallucinated lice.
Neuropsychological testing post-offense (April, 2009) found IQ at the 42%tile; Working Memory, 1%tile; Processing Speed 27%tile; Visual Immediate Memory 7%tile; Booklet Category Test 11%tile; Trailmaking 1%tile; and other findings. Borderline Personality Disorder was identified by the NEO-3. Multiple tests for malingering, including the TOMM, were negative.
Conclusion: Significant mental illness was found, with neuropsychological results consistent with adult-onset neurotoxicity, including mycotoxicosis. The defendant was found not guilty by reason of insanity on some counts, guilty on other counts, spared the death penalty, committed to a mental hospital until cured, and then to prison for life.
The subject was at heightened risk of neurotoxicity from significant exposure to formaldehyde, solvents, products of repeated indoor water intrusion - including mold and mycotoxins (including lysergic acid diethylamide (LSD) resulting from mold in the defendant’s residence) - and pesticides. The additive or synergistic effects of these exposures rendered him delusional, with significant impairment of cognitive, emotional and executive function. Neuropsychological testing was consistent with these impairments.
The defendant suffered from an undiagnosed mental disorder as a child, involving social and cognitive dysfunction. He had significant formaldehyde exposure as a fetus and child. He had a difficult upbringing in his home, was functioning somewhat successfully given his circumstances until exposed to a series of toxic chemicals as a painter, at which time his mental health deteriorated - from the solvent neurotoxicity insult- which permanently sent him into a downward spiral of deteriorating mental health.
As his mental health deteriorated, during 2006-2008, the defendant lived in a very moldy trailer, with environmental LSD exposure from the mycotoxins produced by mold. In his delusional state, he acquired and probably overdosed with pesticides for lice and bedbugs, which would exacerbate his pre-existing mental illness, and result in an acute delusional and confusional state.
The defendant may be viewed as having an underlying thought disorder, such as schizophrenia, which was exacerbated by neurotoxicity from various sources, resulting in delusional psychosis at the time of the shooting.
Mold exposure in the trailer
The extensive moldy condition of the residence was caused by repeated indoor water intrusion. Per environmental inspection, the shingles on roof were faulty, allowing rain to pour in. Among numerous surfaces, the ceiling was extensively moldy. The unit had been moldy since being purchased, with sick previous occupants. See color photographs.
Mold exposure lab reports
Environmental Relative Moldiness Index (ERMI) Report: 3/20/2009. ERMI interpretation: the ERMI takes into account both the quantity of each mold species and the diversity of species present. It measures the long term mold burden. ERMI Level 2 are less likely to have a mold problem; ERMI Level 3 are more likely to have a mold problem; ERMI Level 4 have the greatest likelihood of having a mold problem.
Insulation Ceiling: ERMI Level 2
Bedroom Closet: ERMI Level 4
Pillowcase: ERMI Level 4
Mattress Cover: ERMI Level 4
Kitchen Ceiling: ERMI Level 4
Ceiling over Sink: ERMI Level 3
Mycotoxin Testing Note: All Mycotoxins are reported in parts per billion (ppb) TRICOTHECENES AFLATOXINS OCHRATOXIN A
Ceiling Insulation over Bed 30.463 3.5 2.8
Ceiling Tile Above Kitchen Sink 0 0 9.1
Kitchen Ceiling 0 0 4.9
Plastic and Insulation Bedroom closet 0.901 2.1 9.8
Pillow cover 0 1.4 9.8
Mattress Cover 0 0 28.9
Urine (defendant) Not Present Not Present 14
Trailer Testing
15-Mar-09 FUNGAL CULTURES
Received in lab 17 Mar 09
Refer to COC forms
Living Room R0309031 Penicillium sp.
Scopulariopsis sp.
Aspergillus sp
Bedroom Closet R0309032 Scopulariopsis sp.
Rhizopus sp
Penicillium sp.
Aspergillus sp
Bedroom R0309033 Scopulariopsis sp.
Penicillium sp.
Aspergillus sp
Front Seat - Van R0309034 Penicillium sp.
Aspergillus sp
Kitchen Baby High Chair R0309034 Scopulariopsis sp.
Penicillium sp.
Rhizopus sp.
Aspergillus sp
Van Rear Seat R0309035 Penicillium sp.
Aspergillus sp
Cladasporium sp.
Ergotamines: After acidic extractions of the samples, the specimens were found to contain lysergic acid (LSD) in the samples taken from the ceiling over the bed (57 ng/sample) and the pillow from the bed (86 ng/sample)
Neurobehavioral test results
Age: 28
Gender: Male
Race: White
Height: 6' 00"
Weight: 170
Education: Per parents: dropped out of school as a sophomore at age 15. Educational record review: high school transcript: In 9th and 10th grade, the subject received quite a number of A's, including in subjects such as science, art, physical education, health, occupational education, science, and biology. His grades included A's in Library Science.
Marital status: Never married
Children: 0
Occupation: Mechanic, painter
Premorbid IQ Estimates: Based on a demographic formula which considers current vocabulary scores, education, and occupation, expected pre-morbid IQ would be approximately:
Score Percentile SEe
Full Scale 112 75 8.64
Cognitive Testing Standard: Scores significantly below the standard are considered abnormal for the subject and deficit.
Scaled Score Cutoff
IQ Percent equiv. Scaled/Percentile
112 75 12 8/25
Wechsler Adult Intelligence Scale, Third Edition: WAIS-III:
Age - Adjusted
Scaled Scores Percentile
Verbal Subscales
Vocabulary 13 84
Similarities 10 50
Arithmetic 7 16
Digit Span 4 2
Information 14 91
Comprehension 9 37
Letter-Number
Sequencing 3 1
Performance Subscales
Picture Completion 11 63
Digit Symbol - Coding 8 25
Block Design 10 50
Matrix Reasoning 11 63
Picture Arrangement 9 37
Symbol Search 9 37
Object Assembly 9 37
Score Percentile Confidence Interval - 95%
Verbal IQ: 96 39 91 – 101
Performance IQ: 98 45 91 – 105
Full Scale IQ: 97 42 93 – 101
Index Scores:
Verbal Comprehension 112 79 106 – 117
Perceptual Organization 103 58 96 – 110
Working Memory 67 1 62 – 76
Processing Speed 91 27 83 – 101
Discrepancy Comparisons: Statistical significance 0.05 level
Frequency of Difference in Standardization
Difference Sample
Verbal Comprehension - Working Memory 45 0.5
Verbal Comprehension – Processing Speed 21 17
Interpretation: A decline in cognitive functioning was detected, particularly affecting Working Memory, at the 1st percentile and Processing speed at the 27th percentile. This was further reflected in the contrast between the Verbal Comprehension Index and the Working Memory Index, as well as the Verbal Comprehension Index and the Processing Speed Index, with a statistically very infrequent spread between the two indexes. This finding suggests that there has been a decline affecting working memory and processing speed, consistent with patients with diagnosed neurotoxicity.
Further analysis shows that attentional skills have been compromised, with Digit Span at the 2nd percentile, Letter Number Sequencing at the 1st percentile, and Digit Symbol -- Coding at the 25th percentile.
These findings are consistently with patients with diagnosed neurotoxicity.
Wechsler Memory Scale, Third Edition (WMS-III):
Primary Subtests Age Scaled Score Percentile
Logical Memory I - Recall 8 25
Faces I - Recognition 9 37
Verbal Paired Assoc. I - Recall 9 37
Family Pictures I - Recall 2 <1
Letter-Number Sequencing 3 1
Spatial Span 10 50
Logical Memory II - Recall 9 37
Faces II - Recognition 12 75
Verbal Paired Assoc. II - Recall 13 84
Family Pictures II - Recall 2 <1
Auditory Recognition - Delayed 10 50
Auditory Process Subtests
Logical Memory I
1st Recall Total 9 37
Learning Slope 8 25
Verbal Paired Assoc. I
1st Recall Total 8 25
Learning Slope 12 75
Logical Memory II
Percent Retention 10 50
Verbal Paired Assoc. II
Percent Retention 12 75
Confidence
Primary Index Scores Index Score Percentile Interval (95%)
Auditory Immediate 92 30 85 – 100
Visual Immediate 71 3 66 – 86
Immediate Memory 78 7 72 – 88
Auditory Delayed 105 63 95 – 114
Visual Delayed 81 10 74 – 94
Auditory Recog. Delayed 100 50 89 – 111
General Memory 93 32 86 – 102
Working Memory 81 10 74 – 93
Interpretation: Memory deficits primarily affecting Visual (Immediate and Delayed) and Working Memory. Memory deficits are consistent with patients with diagnosed neurotoxicity.
Benton Visual Retention Test (Administration B, Form C). Comparison IQ = 112
Expected for IQ Observed Difference
Number correct 8 - 1 = 7 3 4
Number errors 2 + 2 = 4 16 12
Interpretation:
Number correct score: Suggested acquired impairment of cognitive functioning.
Number of errors score: Strong indication of acquired impairment of cognitive functioning
The Booklet Categories Test (CT):
Subtest Raw Score
I Errors 0
II Errors 0
III Errors 35
IV Errors 2
V Errors 9
VI Errors 9
VII Errors 5
T-score Percentile
Total Errors 60 38 11
Interpretation: Impaired abstraction or concept formation ability, flexibility in the face of complex and novel problem-solving, and capacity to learn from experience, indicative of brain damage.
Comprehensive Trail-Making Test (CTMT):
Trail # Raw Score T-Score Percentile
1 26 56 72
2 29 52 57
3 41 41 18
4 26 50 50
5 106 22 <1
Interpretation: Deficit on the critical trail #5.
Controlled Oral Word Association Test evaluates verbal fluency, the ability to find and use words.
Raw Score Correction Total Percentile
30 3 33 27
Interpretation: Borderline or possible deficit
Embedded Figures Test evaluates the ability to detect visual figure-ground relationships (the use of the eyes to make sense out of what the eye sees).
Number detected out of 40 objects: 37
Interpretation: Within normal limits
Frontal Systems Behavior Scale (FRSBE)
In this case, before illness refers to the time before solvent exposure
Self Rating
T-score T-score
Before Illness % After Illness %
Apathy 55 69 88 >99
Disinhibition 56 73 80 >99
Executive Dysfunction 44 30 80 >99
Total 55 69 89 >99
Interpretation: Elevated symptoms of frontal lobe damage.
Grooved Pegboard Test: Dominant Hand: Left.
Dominant Non-dominant
Time for completion: 75 s 74 s
Percentile: 22 47
Interpretation: Within normal limits
Neitz Test of Color Vision screens for color vision defects. Number correct of 9 items: 9 Interpretation: Within normal limits
Neurotoxicity Screening Survey:
Factor Results
Score Classification
Memory and Concentration...... 76 Elevated
Autonomic Nervous System...... 62 Elevated
Vision........................ 17 Elevated
Hearing....................... 10 Elevated
Balance....................... 2 Borderline elevated
Smell-Taste.................. 9 Elevated
Peripheral Numbness........... 20 Elevated
Sensory-Motor................. 52 Elevated
Chemical Sensitivity......... 6 Elevated
Emotionality.................. 62 Elevated
Distortion I..................
Overall Neurotoxicity Indicator 316
Interpretation: Results are consistent with patients with diagnosed neurotoxicity.
Selective Reminding Test:
Words continuously remembered, summed over trials (CLTR): 36
Expected: 90
Percentile rank for gender, age and education: 7%
Interpretation: Deficit
Stroop Color and Word Test
Raw Age/Ed
Score Predicted Residual T-Score Percentile
Word reading: 92 99 -7 45 31
Color naming: 58 76 -18 35 7
Color/Word: 41 40 1 51 54
Interpretation: Generally within normal limits
Visual Search and Attention Test:
Left Right Total
Score 72 69 141
Percentile 16 15 15
Interpretation: Deficit Deficit Deficit
EMOTIONAL FUNCTION
Beck Anxiety Inventory measures emotional anxiety. Score: 33
Interpretation: Severe anxiety
Beck Depression Inventory measures emotional depression. Score: 28
Interpretation: Moderate depression
Profile of Mood States
Raw Score T Score %
Tension 22 52 58
Depression** 24 48 42
Anger/Hostility 5 41 18
Vigor 2 38 12
Fatigue 20 59 82
Confusion/Bewilderment 12 48 42
Interpretation: Mood within normal limits at time of testing. Low level of vigorous mood.
WELL-BEING MEASURES
Alcohol Use Disorders Identification Test (AUDIT). Score: 8
Interpretation: Low-medium likelihood of alcohol problems.
Fatigue Severity Scale: Score: 46/9 = 5.1
Interpretation: Consistent with medically ill patients
Quick Environmental Exposure and Sensitivity Inventory, Version 1 (QEESI) identifies health problems respondent may experience in response to various environmental exposures.
Score Interpretation
Chemical Intolerance 26 Medium
Other Intolerance 12 Medium
Symptom Severity 53 High
Masking Index 6 High
Life Impact 49 High
Interpretation: Somewhat suggestive of multiple chemical intolerance.
PERSONALITY TESTING
Revised Neo Personality Inventory: Interpretive report: Summary
Moderately high on the factor Neuroticism, with moderately high levels of negative emotion and the occasional episodes of psychological distress. Such scorers are rather low in self-esteem and somewhat insecure.
Low in Conscientiousness, with a fairly low need for achievement and a tendency not to organize his time well. Raters describe such people as relatively unreliable and careless.
Average range in Agreeableness, Openness, and Extroversion.
Axis II disorders: Personality disorders: Profile agreement between this respondent and the average profile for Borderline Personality Disorder is higher than 90% of subjects in the normative sample, suggesting that the patient may have Borderline features or a Borderline Personality Disorder. No other Axis II disorders were suggested or ruled out.
The respondent can be characterized as: A Gloomy Pessimist, Maladaptive (using primitive and ineffective psychological defenses; lacking insight; cannot verbalize his feelings; may be considered alexithymic (literally "without words for emotions", to describe a state of deficiency in understanding, processing, or describing emotions), Temperamental, and Under - controlled.
DISTORTION AND MALINGERING TESTS
Amnesia Questionnaire assesses the subject's possible mis-reporting memory symptoms. Number correct of 13/13
Interpretation: Non-malingering
Dot Counting Test detects suspect test-taking efforts in adults.
Comparison Group: Mild Dementia
Mean Ungrouped Time 5.5
Mean Grouped Time 2.2
Number of errors 0
Signs of suspect effort
Does mean Grouped time exceed mean Ungrouped time by 1 sec? No
Are there counting errors on Card 6 and/or Card 12? No
E-Score (# of errors plus mean time, ungrouped and group) 7.7
E-Score Cutoff 22
Under test development conditions:
Sensitivity (the test's ability to detect suspect effort) 62%
Specificity (the test's ability to detect normal effort) 94%
Under base rate assumption of 15% population suspect effort:
Positive Predictive Accuracy (the test's ability to detect suspect effort) 64%
Negative Predictive Accuracy(the test's ability to detect normal effort) 93%
Interpretation: Normal effort; non-malingering
Endorsement of Rare Symptoms. The Neurotoxicity Screening Survey presents 14 symptoms that are rare. If a number of these symptoms are endorsed, the question of distortion is highlighted.
Number endorsed: Distortion I: 3; Distortion II: 4
Interpretation: Although distortion or confusion was possible, the total distortion number was not elevated when compared with normal controls.
Memorization of "16" Items: Number correct: 16/16
Interpretation: Non-malingering
Miller Forensic Assessment of Symptoms Test (M-FAST) Total score cutoff = 6. Total Interview Time: 1:45
% Negative % Positive
Raw Score Prediction Prediction
Reported vs. Observed 1
Extreme Symptomatology 1
Rare Combinations 0
Unusual Hallucinations 0
Unusual Symptom Course 0
Negative Image 0
Suggestibility 1
Total 3 99% 57%
Interpretation: Non-malingering
Portland Digit Recognition Test
Percent correct responses (5 sec delay): 3/3
Percent correct responses (15 sec delay): 3/3
Percent correct responses (30 sec delay): 1/1
Interpretation: Non-malingering
Three Word Memory Test
Number correct: 9/9
Interpretation: Non-malingering
Test of Memory Malingering (TOMM): Decision rules: 1) Scoring lower than chance on any trial indicates the possibility of malingering: Scores below 18 are unlikely to occur by chance; 2) any score lower than 45 on Trial 2 or the Retention Trial indicates the possibility of malingering.
Raw Score
Trial 1 31
Trial 2 45
Retention 48
Interpretation: Non-malingering.
Twenty-one Item Memory Test assesses the probability of malingering based on a forced choice comparison. If the subject does not remember correctly nine of the 21 items on the forced choice test, the subject may be malingering.
Number of words correctly recalled:
Free recall: 9
Forced choice: 19
Interpretation: Non-malingering
Recognition testing: Recognition is an easier task than recall.
Recognition test Results Classification
Logical Memory II 26/30 good or better effort
Verbal Paired Associates II 24/24 word pairs excellent effort
Word Lists II (min. 18) 20/24 good or better effort
Visual Reproduction II NA NA
Auditory recognition - Delayed (min. 43) 44 good or better effort
Raymond Singer, Ph.D.
Independent Practice
Santa Fe, New Mexico
and
New York, New York
www.neurotox.com
ray.singer@gmail.com
and
Jack Dwayne Thrasher, Ph.D.
Independent Practice
Citrus Grove, California
Published until April 15, 2012 at: http://neurotox.blogspot.com/
Abstract
In September 2008, a 28-year-old man went on a shooting rampage that left six people dead and four others wounded. Upon arraignment, he told the judge that God told him to kill. The evaluation was conducted to determine if exposure to various neurotoxic agents impacted the defendant's sanity.
Methods: Review of records (criminal, educational, historical, medical, toxicological), diagnostic neuro-psychological interview, family members interview, police reports, and administration of neuropsychological/ behavioral tests.
Results: The defendant had a history of exposure to multiple neurotoxic substances. He lived in a new formaldehyde emitting mobile home from birth to age 14 with psychomotor symptoms. In 2001-2007, he worked as a union painter with resulting headaches and other symptoms. By 2003, there were reports of hallucinations. From 2006-2008, he lived in an extremely moldy trailer. Sampling of the trailer in 2009 found numerous ERMI moldiness index samples were at Level 4, showing the greatest likelihood of having a mold problem; mold and mycotoxin samples found 30.5 ppb trichothecenes; 57 ng/sample LSD from ergotomines in the ceiling, 86 ng on bed pillow; 28.9 ppb ochratoxin A on mattress cover; 14 ppb ochratoxin A in the defendant's urine. In April 2008, he had overdosed dermal exposure to pyrethroids for treating probably hallucinated lice.
Neuropsychological testing post-offense (April, 2009) found IQ at the 42%tile; Working Memory, 1%tile; Processing Speed 27%tile; Visual Immediate Memory 7%tile; Booklet Category Test 11%tile; Trailmaking 1%tile; and other findings. Borderline Personality Disorder was identified by the NEO-3. Multiple tests for malingering, including the TOMM, were negative.
Conclusion: Significant mental illness was found, with neuropsychological results consistent with adult-onset neurotoxicity, including mycotoxicosis. The defendant was found not guilty by reason of insanity on some counts, guilty on other counts, spared the death penalty, committed to a mental hospital until cured, and then to prison for life.
The subject was at heightened risk of neurotoxicity from significant exposure to formaldehyde, solvents, products of repeated indoor water intrusion - including mold and mycotoxins (including lysergic acid diethylamide (LSD) resulting from mold in the defendant’s residence) - and pesticides. The additive or synergistic effects of these exposures rendered him delusional, with significant impairment of cognitive, emotional and executive function. Neuropsychological testing was consistent with these impairments.
The defendant suffered from an undiagnosed mental disorder as a child, involving social and cognitive dysfunction. He had significant formaldehyde exposure as a fetus and child. He had a difficult upbringing in his home, was functioning somewhat successfully given his circumstances until exposed to a series of toxic chemicals as a painter, at which time his mental health deteriorated - from the solvent neurotoxicity insult- which permanently sent him into a downward spiral of deteriorating mental health.
As his mental health deteriorated, during 2006-2008, the defendant lived in a very moldy trailer, with environmental LSD exposure from the mycotoxins produced by mold. In his delusional state, he acquired and probably overdosed with pesticides for lice and bedbugs, which would exacerbate his pre-existing mental illness, and result in an acute delusional and confusional state.
The defendant may be viewed as having an underlying thought disorder, such as schizophrenia, which was exacerbated by neurotoxicity from various sources, resulting in delusional psychosis at the time of the shooting.
Mold exposure in the trailer
The extensive moldy condition of the residence was caused by repeated indoor water intrusion. Per environmental inspection, the shingles on roof were faulty, allowing rain to pour in. Among numerous surfaces, the ceiling was extensively moldy. The unit had been moldy since being purchased, with sick previous occupants. See color photographs.
Mold exposure lab reports
Environmental Relative Moldiness Index (ERMI) Report: 3/20/2009. ERMI interpretation: the ERMI takes into account both the quantity of each mold species and the diversity of species present. It measures the long term mold burden. ERMI Level 2 are less likely to have a mold problem; ERMI Level 3 are more likely to have a mold problem; ERMI Level 4 have the greatest likelihood of having a mold problem.
Insulation Ceiling: ERMI Level 2
Bedroom Closet: ERMI Level 4
Pillowcase: ERMI Level 4
Mattress Cover: ERMI Level 4
Kitchen Ceiling: ERMI Level 4
Ceiling over Sink: ERMI Level 3
Mycotoxin Testing Note: All Mycotoxins are reported in parts per billion (ppb) TRICOTHECENES AFLATOXINS OCHRATOXIN A
Ceiling Insulation over Bed 30.463 3.5 2.8
Ceiling Tile Above Kitchen Sink 0 0 9.1
Kitchen Ceiling 0 0 4.9
Plastic and Insulation Bedroom closet 0.901 2.1 9.8
Pillow cover 0 1.4 9.8
Mattress Cover 0 0 28.9
Urine (defendant) Not Present Not Present 14
Trailer Testing
15-Mar-09 FUNGAL CULTURES
Received in lab 17 Mar 09
Refer to COC forms
Living Room R0309031 Penicillium sp.
Scopulariopsis sp.
Aspergillus sp
Bedroom Closet R0309032 Scopulariopsis sp.
Rhizopus sp
Penicillium sp.
Aspergillus sp
Bedroom R0309033 Scopulariopsis sp.
Penicillium sp.
Aspergillus sp
Front Seat - Van R0309034 Penicillium sp.
Aspergillus sp
Kitchen Baby High Chair R0309034 Scopulariopsis sp.
Penicillium sp.
Rhizopus sp.
Aspergillus sp
Van Rear Seat R0309035 Penicillium sp.
Aspergillus sp
Cladasporium sp.
Ergotamines: After acidic extractions of the samples, the specimens were found to contain lysergic acid (LSD) in the samples taken from the ceiling over the bed (57 ng/sample) and the pillow from the bed (86 ng/sample)
Neurobehavioral test results
Age: 28
Gender: Male
Race: White
Height: 6' 00"
Weight: 170
Education: Per parents: dropped out of school as a sophomore at age 15. Educational record review: high school transcript: In 9th and 10th grade, the subject received quite a number of A's, including in subjects such as science, art, physical education, health, occupational education, science, and biology. His grades included A's in Library Science.
Marital status: Never married
Children: 0
Occupation: Mechanic, painter
Premorbid IQ Estimates: Based on a demographic formula which considers current vocabulary scores, education, and occupation, expected pre-morbid IQ would be approximately:
Score Percentile SEe
Full Scale 112 75 8.64
Cognitive Testing Standard: Scores significantly below the standard are considered abnormal for the subject and deficit.
Scaled Score Cutoff
IQ Percent equiv. Scaled/Percentile
112 75 12 8/25
Wechsler Adult Intelligence Scale, Third Edition: WAIS-III:
Age - Adjusted
Scaled Scores Percentile
Verbal Subscales
Vocabulary 13 84
Similarities 10 50
Arithmetic 7 16
Digit Span 4 2
Information 14 91
Comprehension 9 37
Letter-Number
Sequencing 3 1
Performance Subscales
Picture Completion 11 63
Digit Symbol - Coding 8 25
Block Design 10 50
Matrix Reasoning 11 63
Picture Arrangement 9 37
Symbol Search 9 37
Object Assembly 9 37
Score Percentile Confidence Interval - 95%
Verbal IQ: 96 39 91 – 101
Performance IQ: 98 45 91 – 105
Full Scale IQ: 97 42 93 – 101
Index Scores:
Verbal Comprehension 112 79 106 – 117
Perceptual Organization 103 58 96 – 110
Working Memory 67 1 62 – 76
Processing Speed 91 27 83 – 101
Discrepancy Comparisons: Statistical significance 0.05 level
Frequency of Difference in Standardization
Difference Sample
Verbal Comprehension - Working Memory 45 0.5
Verbal Comprehension – Processing Speed 21 17
Interpretation: A decline in cognitive functioning was detected, particularly affecting Working Memory, at the 1st percentile and Processing speed at the 27th percentile. This was further reflected in the contrast between the Verbal Comprehension Index and the Working Memory Index, as well as the Verbal Comprehension Index and the Processing Speed Index, with a statistically very infrequent spread between the two indexes. This finding suggests that there has been a decline affecting working memory and processing speed, consistent with patients with diagnosed neurotoxicity.
Further analysis shows that attentional skills have been compromised, with Digit Span at the 2nd percentile, Letter Number Sequencing at the 1st percentile, and Digit Symbol -- Coding at the 25th percentile.
These findings are consistently with patients with diagnosed neurotoxicity.
Wechsler Memory Scale, Third Edition (WMS-III):
Primary Subtests Age Scaled Score Percentile
Logical Memory I - Recall 8 25
Faces I - Recognition 9 37
Verbal Paired Assoc. I - Recall 9 37
Family Pictures I - Recall 2 <1
Letter-Number Sequencing 3 1
Spatial Span 10 50
Logical Memory II - Recall 9 37
Faces II - Recognition 12 75
Verbal Paired Assoc. II - Recall 13 84
Family Pictures II - Recall 2 <1
Auditory Recognition - Delayed 10 50
Auditory Process Subtests
Logical Memory I
1st Recall Total 9 37
Learning Slope 8 25
Verbal Paired Assoc. I
1st Recall Total 8 25
Learning Slope 12 75
Logical Memory II
Percent Retention 10 50
Verbal Paired Assoc. II
Percent Retention 12 75
Confidence
Primary Index Scores Index Score Percentile Interval (95%)
Auditory Immediate 92 30 85 – 100
Visual Immediate 71 3 66 – 86
Immediate Memory 78 7 72 – 88
Auditory Delayed 105 63 95 – 114
Visual Delayed 81 10 74 – 94
Auditory Recog. Delayed 100 50 89 – 111
General Memory 93 32 86 – 102
Working Memory 81 10 74 – 93
Interpretation: Memory deficits primarily affecting Visual (Immediate and Delayed) and Working Memory. Memory deficits are consistent with patients with diagnosed neurotoxicity.
Benton Visual Retention Test (Administration B, Form C). Comparison IQ = 112
Expected for IQ Observed Difference
Number correct 8 - 1 = 7 3 4
Number errors 2 + 2 = 4 16 12
Interpretation:
Number correct score: Suggested acquired impairment of cognitive functioning.
Number of errors score: Strong indication of acquired impairment of cognitive functioning
The Booklet Categories Test (CT):
Subtest Raw Score
I Errors 0
II Errors 0
III Errors 35
IV Errors 2
V Errors 9
VI Errors 9
VII Errors 5
T-score Percentile
Total Errors 60 38 11
Interpretation: Impaired abstraction or concept formation ability, flexibility in the face of complex and novel problem-solving, and capacity to learn from experience, indicative of brain damage.
Comprehensive Trail-Making Test (CTMT):
Trail # Raw Score T-Score Percentile
1 26 56 72
2 29 52 57
3 41 41 18
4 26 50 50
5 106 22 <1
Interpretation: Deficit on the critical trail #5.
Controlled Oral Word Association Test evaluates verbal fluency, the ability to find and use words.
Raw Score Correction Total Percentile
30 3 33 27
Interpretation: Borderline or possible deficit
Embedded Figures Test evaluates the ability to detect visual figure-ground relationships (the use of the eyes to make sense out of what the eye sees).
Number detected out of 40 objects: 37
Interpretation: Within normal limits
Frontal Systems Behavior Scale (FRSBE)
In this case, before illness refers to the time before solvent exposure
Self Rating
T-score T-score
Before Illness % After Illness %
Apathy 55 69 88 >99
Disinhibition 56 73 80 >99
Executive Dysfunction 44 30 80 >99
Total 55 69 89 >99
Interpretation: Elevated symptoms of frontal lobe damage.
Grooved Pegboard Test: Dominant Hand: Left.
Dominant Non-dominant
Time for completion: 75 s 74 s
Percentile: 22 47
Interpretation: Within normal limits
Neitz Test of Color Vision screens for color vision defects. Number correct of 9 items: 9 Interpretation: Within normal limits
Neurotoxicity Screening Survey:
Factor Results
Score Classification
Memory and Concentration...... 76 Elevated
Autonomic Nervous System...... 62 Elevated
Vision........................ 17 Elevated
Hearing....................... 10 Elevated
Balance....................... 2 Borderline elevated
Smell-Taste.................. 9 Elevated
Peripheral Numbness........... 20 Elevated
Sensory-Motor................. 52 Elevated
Chemical Sensitivity......... 6 Elevated
Emotionality.................. 62 Elevated
Distortion I..................
Overall Neurotoxicity Indicator 316
Interpretation: Results are consistent with patients with diagnosed neurotoxicity.
Selective Reminding Test:
Words continuously remembered, summed over trials (CLTR): 36
Expected: 90
Percentile rank for gender, age and education: 7%
Interpretation: Deficit
Stroop Color and Word Test
Raw Age/Ed
Score Predicted Residual T-Score Percentile
Word reading: 92 99 -7 45 31
Color naming: 58 76 -18 35 7
Color/Word: 41 40 1 51 54
Interpretation: Generally within normal limits
Visual Search and Attention Test:
Left Right Total
Score 72 69 141
Percentile 16 15 15
Interpretation: Deficit Deficit Deficit
EMOTIONAL FUNCTION
Beck Anxiety Inventory measures emotional anxiety. Score: 33
Interpretation: Severe anxiety
Beck Depression Inventory measures emotional depression. Score: 28
Interpretation: Moderate depression
Profile of Mood States
Raw Score T Score %
Tension 22 52 58
Depression** 24 48 42
Anger/Hostility 5 41 18
Vigor 2 38 12
Fatigue 20 59 82
Confusion/Bewilderment 12 48 42
Interpretation: Mood within normal limits at time of testing. Low level of vigorous mood.
WELL-BEING MEASURES
Alcohol Use Disorders Identification Test (AUDIT). Score: 8
Interpretation: Low-medium likelihood of alcohol problems.
Fatigue Severity Scale: Score: 46/9 = 5.1
Interpretation: Consistent with medically ill patients
Quick Environmental Exposure and Sensitivity Inventory, Version 1 (QEESI) identifies health problems respondent may experience in response to various environmental exposures.
Score Interpretation
Chemical Intolerance 26 Medium
Other Intolerance 12 Medium
Symptom Severity 53 High
Masking Index 6 High
Life Impact 49 High
Interpretation: Somewhat suggestive of multiple chemical intolerance.
PERSONALITY TESTING
Revised Neo Personality Inventory: Interpretive report: Summary
Moderately high on the factor Neuroticism, with moderately high levels of negative emotion and the occasional episodes of psychological distress. Such scorers are rather low in self-esteem and somewhat insecure.
Low in Conscientiousness, with a fairly low need for achievement and a tendency not to organize his time well. Raters describe such people as relatively unreliable and careless.
Average range in Agreeableness, Openness, and Extroversion.
Axis II disorders: Personality disorders: Profile agreement between this respondent and the average profile for Borderline Personality Disorder is higher than 90% of subjects in the normative sample, suggesting that the patient may have Borderline features or a Borderline Personality Disorder. No other Axis II disorders were suggested or ruled out.
The respondent can be characterized as: A Gloomy Pessimist, Maladaptive (using primitive and ineffective psychological defenses; lacking insight; cannot verbalize his feelings; may be considered alexithymic (literally "without words for emotions", to describe a state of deficiency in understanding, processing, or describing emotions), Temperamental, and Under - controlled.
DISTORTION AND MALINGERING TESTS
Amnesia Questionnaire assesses the subject's possible mis-reporting memory symptoms. Number correct of 13/13
Interpretation: Non-malingering
Dot Counting Test detects suspect test-taking efforts in adults.
Comparison Group: Mild Dementia
Mean Ungrouped Time 5.5
Mean Grouped Time 2.2
Number of errors 0
Signs of suspect effort
Does mean Grouped time exceed mean Ungrouped time by 1 sec? No
Are there counting errors on Card 6 and/or Card 12? No
E-Score (# of errors plus mean time, ungrouped and group) 7.7
E-Score Cutoff 22
Under test development conditions:
Sensitivity (the test's ability to detect suspect effort) 62%
Specificity (the test's ability to detect normal effort) 94%
Under base rate assumption of 15% population suspect effort:
Positive Predictive Accuracy (the test's ability to detect suspect effort) 64%
Negative Predictive Accuracy(the test's ability to detect normal effort) 93%
Interpretation: Normal effort; non-malingering
Endorsement of Rare Symptoms. The Neurotoxicity Screening Survey presents 14 symptoms that are rare. If a number of these symptoms are endorsed, the question of distortion is highlighted.
Number endorsed: Distortion I: 3; Distortion II: 4
Interpretation: Although distortion or confusion was possible, the total distortion number was not elevated when compared with normal controls.
Memorization of "16" Items: Number correct: 16/16
Interpretation: Non-malingering
Miller Forensic Assessment of Symptoms Test (M-FAST) Total score cutoff = 6. Total Interview Time: 1:45
% Negative % Positive
Raw Score Prediction Prediction
Reported vs. Observed 1
Extreme Symptomatology 1
Rare Combinations 0
Unusual Hallucinations 0
Unusual Symptom Course 0
Negative Image 0
Suggestibility 1
Total 3 99% 57%
Interpretation: Non-malingering
Portland Digit Recognition Test
Percent correct responses (5 sec delay): 3/3
Percent correct responses (15 sec delay): 3/3
Percent correct responses (30 sec delay): 1/1
Interpretation: Non-malingering
Three Word Memory Test
Number correct: 9/9
Interpretation: Non-malingering
Test of Memory Malingering (TOMM): Decision rules: 1) Scoring lower than chance on any trial indicates the possibility of malingering: Scores below 18 are unlikely to occur by chance; 2) any score lower than 45 on Trial 2 or the Retention Trial indicates the possibility of malingering.
Raw Score
Trial 1 31
Trial 2 45
Retention 48
Interpretation: Non-malingering.
Twenty-one Item Memory Test assesses the probability of malingering based on a forced choice comparison. If the subject does not remember correctly nine of the 21 items on the forced choice test, the subject may be malingering.
Number of words correctly recalled:
Free recall: 9
Forced choice: 19
Interpretation: Non-malingering
Recognition testing: Recognition is an easier task than recall.
Recognition test Results Classification
Logical Memory II 26/30 good or better effort
Verbal Paired Associates II 24/24 word pairs excellent effort
Word Lists II (min. 18) 20/24 good or better effort
Visual Reproduction II NA NA
Auditory recognition - Delayed (min. 43) 44 good or better effort
Monday, March 07, 2011
Chronic Neurotoxicity From Chronic Mold Exposure
Singer, R. (2011). Chronic neurotoxicity after chronic mold exposure. Presented at the 50th Annual Meeting of the Society of Toxicology, Washington, March 7th.
Chronic Neurotoxicity after
Chronic Mold Exposure
Raymond Singer, Ph.D.
Board-Certified Neuropsychologist
Santa Fe, New Mexico, and
New York, New York
Rationale: The products of repeated indoor water intrusions, as well as their distribution cycles, are complex. Toxic products include mold parts (fungi contain glucan - a polyglucose compound - in the cell wall, which can induce a defect in macrophage control of other inflammatory cell types at very low levels of exposure; hyphae); neurotoxic volatile organic hydrocarbons (Toxicological Sciences 117(2), 418–426 (2010)); neurotoxic mycotoxins; spores, which can transmit infections; endotoxic bacteria, and possibly other substances. Their distribution will vary depending upon humidity cycles.
The products of repeated indoor water intrusions will be referred to as “mold” in this paper. There have been a number of groups studies and case reports describing the neurotoxicity of chronic exposure to mold. However, the method to diagnose mold neurotoxicity in an individual case is a developing art and science.
Objective: 1) present a method for the individual diagnose of mold neurotoxicity; 2) demonstrate that it is possible to diagnose mold neurotoxicity in an individual case.
Subject: Female, 56 years old, divorced, 3 grown children. Education: Ivy League graduate in 3 years, Magna Cum Laude and Phi Beta Kappa; MA in Economics from a highly competitive university with an A average; law degree - top ten percent of her class at top-ranked law school. Spoke 4 languages.
Employment: Unemployed following her illness. Former director, energy and software financial development companies; former deputy chief lawyer for a cabinet-level Federal department.
Exposure: Resided in a contaminated, well-known, prestigious condominium for 1.5 years. Shortly after moving into the contaminated residence, she developed flu-like symptoms with nasal congestion, burning eyes, and fatigue.
Source of Mold: The washing machine overflowed, spilling water throughout the condominium. When repairing the water damage, black mold became visible behind the baseboards along the walls. Thereafter, a series of extensive piecemeal repairs was performed.
Additional mold was discovered throughout the condominium as the repairs progressed from room to room, some due to leaks from faulty plumbing in several rooms. With each of these attempted repairs, walls were torn out without the utilization of proper abatement procedures, releasing contaminants into the air in a failed effort to fix the problems. Most of the moisture inside the walls came from roof leaks and the flood. Some leaks appeared after roofing repairs.
Various interior wall shafts were not inspected for mold, which was discovered later. The contents of the apartment were not properly protected. Without such protection, the contents were exposed to harmful contaminants and other particulate matter. Apparently, the air vents were not adequately protected, so that airborne mold spores contaminated the unit's HVAC system.
Environmental testing: An industrial hygienist reported: The building clearly had a history of a wide range of leaks and water intrusion due to design, construction and maintenance issues, eventually leading to water damage, mold and bacterial growth, and leading to human exposure. The mold problems were compounded by conducting investigation, sampling and testing in a piecemeal manner. Unit occupants were allowed in the building while destructive testing and remediation were being conducted in some units. This inevitably led to exposures.
The mold including stachybotrys (SB) (3,424 counts of fungal structure (FS); 91,307 FS/m3, 97% of sample, categorized as massive fungal growth, with black mold in many locations in the apartment, including air samples of 260 particulates SB/M3.
Assessment approach: Comprehensive neurobehavioral toxicity evaluations were performed on 5 occasions two-seven years post-exposure. The assessment included extensive diagnostic interviews, administration of tests which have established normative bases and which are known to be sensitive to neurotoxicity, tests for effort, malingering, distortion, hypochondria, and record review (exposure, medical).
Findings:
Current symptoms: The subject reported the following current symptoms:
Severe cognitive problems
Short term memory loss
Multiple chemical sensitivity (MCS)
Respiratory symptoms on exposure; asthma on extreme exposures
Visual disturbance MCS symptom
Reduced sensation in extremities
Weakness in left hand
Joint pain
Headaches
Sleep Disorder: Sleeps up to 16 hours a day and still fatigued.
Urinary frequency and swelling
The Neurotoxicity Screening Survey (included in Appendix 1) shows a symptom constellation consistent with neurotoxicity in the following categories:
Memory and Concentration
Autonomic Nervous System
Vision
Hearing
Balance
Smell-Taste
Peripheral Numbness
Sensory-Motor
Chemical Sensitivity
Emotionality
Test results:
Blood marker: SB IgE was 51 ELISA units, above the reference range of 50.
Imaging: MRI showed right temporal lobe abnormality.
Electrophysiological testing:
Visual Evoked Potentials: Impression: Visual evoked response study was abnormal bilaterally.
Somatosensory Evoked Potentials: somatosensory evoked potential responses were recorded from each lower extremity by stimulating at the ankle and by recording over the lumbar point and the contralateral sensory cortex. There is prolongation of the absolute latency on the left and borderline on the right. The amplitudes of the waveforms were decreased and poorly developed. Impression: left abnormal due to prolongation at the lumbar plexus and borderline right.
Cognitive function: See Appendix 1. Her Full Scale IQ prior to exposure was estimated to be at the 97 percentile (pct). Initial testing found WAIS-III Working Memory at the 5pct; WMS-III Working Memory 13pct; Selective Reminding Test 11 pct; Comprehensive Trail-Making Test 9pct; Stroop Color and Word Test 7 pct. These results indicate a significant decline in memory and executive function.
Results of the Neurotoxicity Screening Survey were elevated (436) and consistent with neurotoxicity, with Symptom Distortion not indicated.
Repeated testing over 5 years after being removed from exposure found overall cognitive function partially improved, but her function did not return to prior levels.
Personality testing using the NEO Personality Inventory found no significant personality disorder, and did not suggest somatisizing (hypochondria).
Medical record review found no competing explanations of his illness.
See Appendix 1 for a listing of the neurobehavioral test results.
Conclusion: Mold exposure can cause neurotoxicity, revealed by neurobehavioral evaluation, lasting many years after exposure.Appendix 1: Neurobehavioral test results as of 2008
Wechsler Adult Intelligence Scale, Third Edition: WAIS-III:
(In parentheses, under column heading percentile, from tests administered in 2003, 2 years after the exposure began)
Age - Adjusted
Scaled Scores Percentile Classification of change since 2003
Verbal Subscales
Arithmetic 5 5 (02) Some improvement, but still quite deficit
Digit Span 10 50 (16) Improvement, but still deficit for you
Letter-Number
Sequencing 13 84 (16) Improvement
Performance Subscales
Digit Symbol - Coding 9 37 (50) Decrease
Block Design 10 50 (75) Decrease
Object Assembly 10 50 Not previously administered
Object Assembly results are deficit for the subject, showing why she might be having difficulty in directions and getting lost.
Score Percentile Confidence Interval - 90%
Index Scores:
Working Memory 95 37 90 - 101
(5) Improvement
Interpretation: Overall, the subject is still showing cognitive deficits when compared with her pre-exposure level of function. Some functions mildly improved, and some functions declined. Overall memory function as measured by this test improved to the 37th percentile, however, this is still a deficit function for the subject. Mental arithmetic skills are still quite poor.
Wechsler Memory Scale, Third Edition (WMS-III):
Primary Subtests Age Scaled Score Percentile
Logical Memory I - Recall 14 91
Verbal Paired Assoc. I - Recall 10 50
Logical Memory II - Recall 11 63
Verbal Paired Assoc. II - Recall 10 50
Auditory Recognition - Delayed 15 95
Auditory Process Subtests
Logical Memory I
1st Recall Total 13 84
Learning Slope 15 95
Verbal Paired Assoc. I
1st Recall Total 11 63
Learning Slope 11 63
Logical Memory II
Percent Retention 7 25
Verbal Paired Assoc. II
Percent Retention 9 37
Confidence
Primary Index Scores Index Score Percentile Interval (90%)
Auditory Immediate 111 77 104 - 116
(47) Improvement
Auditory Delayed 102 55 94 - 110
(87) Decreased
Auditory Recog. Delayed 125 95 109 - 128
(91) Unchanged
Sum of
Auditory Process Composites Scaled Scores Percentile
Single Trial Learning 24 78
Learning Slope 26 89
Retention 17 25
Retrieval 5 97
Primary Index Differences Frequency of
Difference in
Standardization
Difference Sample
AD - ARD -23 6.9
Interpretation: Declines continue to be found in verbal memory. The primary problem appears to be difficulty in retention of learned material.
Benton Visual Retention Test (Administration B, Form C). This test assesses the ability to remember, based upon visual input. Comparison IQ = 128
Expected for IQ Observed Difference
Number correct 6 8 +2
(7)
Number errors 5 3 -2
(4)
Interpretation: Unchanged
Number Correct Score: Within Normal Limits.
Number of Errors Score: Within Normal Limits.
Benton Visual Retention Test (Administration B, Form C). This test assesses the ability to remember, based upon visual input. Comparison IQ = 128
Results as of 7/27/2004
Expected for IQ Observed Difference
Number correct 6 6 0
Number errors 5 5 0
Interpretation:
Number Correct Score: Within normal limits.
Number of Errors Score: Within normal limits.
The Booklet Category Test
Raw Score T-score Percentile
I Errors 0
II Errors 0
III Errors 4
IV Errors 1
V Errors 9
VI Errors 7
VII Errors 2
Total Errors 23 61 86
Interpretation: Within normal limits. This test was not given previously.
Comprehensive Trail-Making Test (CTMT) comprises a standardized set of five visual search and sequencing tasks that are heavily influenced by attention, concentration, resistance to distraction, and cognitive flexibility, in addition to visual search and sequencing demands. The CTMT may be useful in neuropsychological assessment generally for the purposes of detecting brain compromise... including the detection of frontal lobe deficits; problems with psychomotor speed, visual search and sequencing, and attention; and impairments in set-shifting.
Trail # Raw Score T-Score Percentile Description
1 34 55 69 Average
2 42 52 58 Average
3 53 46 35 Average
4 38 53 62 Average
5 108 39 14 Below Average
(16) Unchanged
Total 245
Composite Index 48 43
(9) Improved
Interpretation: Although there was an improvement in the composite index, in the critical trail number five, the results were unchanged.
Testing: 7/27/04
Trail # Raw Score T-Score Percentile Description
1 39 52 58 Average
2 41 53 62 Average
3 41 55 69 Average
4 31 59 82 Average
5 71 49 46 Average
Total 268
Composite Index 54 67
Interpretation: Showed some improvement compared with prior testing, and post testing.
Controlled Oral Word Association Test evaluates verbal fluency, the ability to find and use words (Benton Controlled Oral Word Association Test: Reliability and updated norms. RM Ruff et al. Archives of Clinical Neuropsychology, 11(4), 329-338, 1996).
Raw Score Correction Total Percentile Classification
31 31 -7 = 24 4.5 Deficient
Interpretation: Previously 21st percentile: decreased
Perseverations: 0
Frontal Systems Behavior Scale (FRSBE) is a rating scale designed to measure behaviors associated with damage to the frontal lobes and frontal systems of the brain.
Self Rating
T-score T-score
Before Illness % After Illness %
Apathy 52 58 94 >99
Disinhibition 71 98 71 98
Executive Dysfunction 56 73% 82 >99
Total 82 >99
Interpretation: Similar as before.
Grooved Pegboard Test evaluates manual dexterity (the ability to use hands in a sensitive and productive way). Dominant Hand:
Dominant Non-dominant
Time for completion: 100 s 88 s
Percentile: 1.4 16
Interpretation: Deficit. Similar as before. Note somatosensory evoked potential abnormalities as described in an above section of this report.
Neitz Test of Color Vision screens for color vision defects.
Number correct of 9 items: 4/9
Interpretation: Moderate Unspecified Deficiency/ Significant Tritan Deficiency
Neurotoxicity Screening Survey:
Factor Results
Score Classification
Memory and Concentration...... 104 Elevated
Autonomic Nervous System...... 71 Elevated
Vision........................ 18 Elevated
Hearing....................... 5 Within Normal Limits
Balance....................... 2 Borderline
Smell-Taste................... 6 Elevated
Peripheral Numbness........... 15 Elevated
Sensory-Motor................. 42 Elevated
Chemical Sensitivity.......... 10 Elevated
Emotionality.................. 45 Elevated
Distortion I.................. 8 Within Normal Limits
Distortion II................. 7 Within Normal Limits
Overall Neurotoxicity Indicator 318 Elevated
Interpretation: Results consistent with those of patients diagnosed with neurotoxicity.
Paced Auditory Serial Addition Test evaluates auditory information processing and tracking.
Subject was unable to perform this test, so the testing was discontinued.
Interpretation: Deficit
Ruff Figural Fluency Test measures nonverbal fluency analogous to the verbal tests that require the respondent to generate as many words as possible starting with a specific letter of the alphabet.
Error Education
Raw Ratio Correction Total Percentile Interpretation
Unique Designs 42 - 7 35 1-5% Impaired
Perseverations 7 0.175 -0.03 0.145 69% Average
Interpretation: Deficit
Selective Reminding Test evaluates the ability to learn. A list of words is read, followed by free recall. After each trial and subsequent recall, the subject is reminded of words that were missed. Twelve trials are administered.
Words continuously remembered, summed over trials (CLTR): 40
Expected: 74.1
Percentile rank for gender, age and education: 15%
Interpretation: Deficit. Previously 11%, similar.
Stroop Color and Word Test evaluates mental flexibility (45 sec administration).
Raw Age/Ed
Score Predicted Residual T-Score Percentile
Word reading: 79 113 -34 26 <1
Color naming: 60 81 -21 33 5
Color/Word: 31 46 -15 35 7
Interference: 31 35 - 4 46 35
Interpretation: Deficit - similar as in the past
Visual Search and Attention Test This test measures visual scanning and sustained attention. The measurement of attentional processes is an important element in the assessment of brain-damaged patients or individuals with suspected cognitive deficits. Attention and concentration are commonly impaired in individuals who have suffered brain damage and impairment in these abilities is often a prominent residual effect of brain damage
Left Right Total
Score 43 36 79
Percentile 25 21 22
Interpretation: Deficit - but improved
EMOTIONAL FUNCTION
Beck Anxiety Inventory measures emotional anxiety*. Score: 22
Interpretation: Moderate Anxiety (Improved)
Beck Depression Inventory measures emotional depression**. Score: 23
Interpretation: Moderate to Severe Depression (Similar)
Profile of Mood States
Raw Score T Score %
Tension 15 44 27
Depression** 18 44 27
Anger/Hostility 6 42 22
Vigor 3 40 16
Fatigue 21 60 84
Confusion/Bewilderment 20 60 84
Interpretation: Not depressed at time of testing. High levels of fatigue and confusion.
WELL-BEING MEASURES
Alcohol Use Disorders Identification Test (AUDIT) was developed by the World Health Organization to identify alcohol use disorders. Cutoff = 8
Score: 1
Interpretation: Alcohol use problems are unlikely.
Fatigue Severity Scale identifies fatigue with features that are specific to the medically ill. These features are largely independent of depressive symptoms of fatigue.
Mean score: 6.1
Interpretation: Consistent with medically ill patients - similar as in past
General Well Being Schedule evaluates general well-being compared with the population of the US.
Score: 45
0-60 Severe Distress
Human Activity Profile measures levels of physical activity.
Score Percentile
Maximum Activity Score 79 71
Adjusted Activity Score 69 33
Activity Age 51
Activity Classification Moderately Active
Dyspnea Scale 7 41
Interpretation: Within Normal Limits
Quick Environmental Exposure and Sensitivity Inventory, Version 1 (QEESI) identifies health problems respondent may experience in response to various environmental exposures.
Score Interpretation
Chemical Intolerance 89 High
Other Intolerance 58 High
Symptom Severity 71 High
Masking Index 1 Low
Life Impact 94 High
Interpretation: Very Suggestive of Multiple Chemical Intolerance. Similar as in past.
DISTORTION AND MALINGERING TESTS
Absurd responding detects a patient responding an nonsensical way.
Results: 0/3
Interpretation: Non-malingering
Dot Counting Test detects suspect test-taking efforts in adults.
Comparison Group: Mild Dementia
Mean Ungrouped Time 7.8
Mean Grouped Time 5.6
Number of errors 1
Signs of suspect effort
Does mean Grouped time exceed mean Ungrouped time by 1 sec? No
Are there counting errors on Card 6 and/or Card 12? No
E-Score (# of errors plus mean time, ungrouped and group) 15
E-Score Cutoff 22
Under test development conditions:
Sensitivity (the test’s ability to detect suspect effort) 62%
Specificity (the test’s ability to detect normal effort) 94%
Under base rate assumption of 15% population suspect effort:
Positive Predictive Accuracy
(the test’s ability to detect suspect effort) 64%
Negative Predictive Accuracy
(the test’s ability to detect normal effort) 93%
Interpretation: Normal effort
Dot Counting Test detects suspect test-taking efforts in adults. Testing: 7/27/04
Comparison Group: Mild Dementia
Mean Ungrouped Time 7.2
Mean Grouped Time 3.2
Number of errors 0
Signs of suspect effort
Does mean Grouped time exceed mean Ungrouped time by 1 sec? No
Are there counting errors on Card 6 and/or Card 12? No
E-Score (# of errors plus mean time, ungrouped and group) 11
E-Score Cutoff 22
Under test development conditions:
Sensitivity (the test’s ability to detect suspect effort) 62%
Specificity (the test’s ability to detect normal effort) 94%
Under base rate assumption of 15% population suspect effort:
Positive Predictive Accuracy
(the test’s ability to detect suspect effort) 64%
Negative Predictive Accuracy
(the test’s ability to detect normal effort) 93%
Interpretation: Normal effort
Miller Forensic Assessment of Symptoms Test (M-FAST) provides information regarding the probability that an individual is malingering psychiatric illness based on a structured interview. Administered 7/27/04. Total score cutoff = 6.
% Negative % Positive
Raw Score Prediction Prediction
Reported vs. Observed 0
Extreme Symptomatology 0
Rare Combinations 0
Unusual Hallucinations 0
Unusual Symptom Course 0
Negative Image 0
Suggestibility 0
Total 0 100% <48%
Interpretation: Honest responder
Three Word Memory Test evaluates the presence of a memory disorder. A malingering subject may remember less than 40% of the words.
Number correct: 12/12
Interpretation: Non-malingering
TOMM
Raw Score
Trial 1 48
Trial 2 50
Retention 50
Interpretation: Good effort
Recognition testing: Recognition is an easier task than recall.
Recognition test*** Results Classification
Logical Memory II 29/30 excellent effort
Verbal Paired Associates II 24/24 word pairs excellent effort
Auditory recognition - Delayed (min 43) 53 good or better effort
Chronic Neurotoxicity after
Chronic Mold Exposure
Raymond Singer, Ph.D.
Board-Certified Neuropsychologist
Santa Fe, New Mexico, and
New York, New York
Rationale: The products of repeated indoor water intrusions, as well as their distribution cycles, are complex. Toxic products include mold parts (fungi contain glucan - a polyglucose compound - in the cell wall, which can induce a defect in macrophage control of other inflammatory cell types at very low levels of exposure; hyphae); neurotoxic volatile organic hydrocarbons (Toxicological Sciences 117(2), 418–426 (2010)); neurotoxic mycotoxins; spores, which can transmit infections; endotoxic bacteria, and possibly other substances. Their distribution will vary depending upon humidity cycles.
The products of repeated indoor water intrusions will be referred to as “mold” in this paper. There have been a number of groups studies and case reports describing the neurotoxicity of chronic exposure to mold. However, the method to diagnose mold neurotoxicity in an individual case is a developing art and science.
Objective: 1) present a method for the individual diagnose of mold neurotoxicity; 2) demonstrate that it is possible to diagnose mold neurotoxicity in an individual case.
Subject: Female, 56 years old, divorced, 3 grown children. Education: Ivy League graduate in 3 years, Magna Cum Laude and Phi Beta Kappa; MA in Economics from a highly competitive university with an A average; law degree - top ten percent of her class at top-ranked law school. Spoke 4 languages.
Employment: Unemployed following her illness. Former director, energy and software financial development companies; former deputy chief lawyer for a cabinet-level Federal department.
Exposure: Resided in a contaminated, well-known, prestigious condominium for 1.5 years. Shortly after moving into the contaminated residence, she developed flu-like symptoms with nasal congestion, burning eyes, and fatigue.
Source of Mold: The washing machine overflowed, spilling water throughout the condominium. When repairing the water damage, black mold became visible behind the baseboards along the walls. Thereafter, a series of extensive piecemeal repairs was performed.
Additional mold was discovered throughout the condominium as the repairs progressed from room to room, some due to leaks from faulty plumbing in several rooms. With each of these attempted repairs, walls were torn out without the utilization of proper abatement procedures, releasing contaminants into the air in a failed effort to fix the problems. Most of the moisture inside the walls came from roof leaks and the flood. Some leaks appeared after roofing repairs.
Various interior wall shafts were not inspected for mold, which was discovered later. The contents of the apartment were not properly protected. Without such protection, the contents were exposed to harmful contaminants and other particulate matter. Apparently, the air vents were not adequately protected, so that airborne mold spores contaminated the unit's HVAC system.
Environmental testing: An industrial hygienist reported: The building clearly had a history of a wide range of leaks and water intrusion due to design, construction and maintenance issues, eventually leading to water damage, mold and bacterial growth, and leading to human exposure. The mold problems were compounded by conducting investigation, sampling and testing in a piecemeal manner. Unit occupants were allowed in the building while destructive testing and remediation were being conducted in some units. This inevitably led to exposures.
The mold including stachybotrys (SB) (3,424 counts of fungal structure (FS); 91,307 FS/m3, 97% of sample, categorized as massive fungal growth, with black mold in many locations in the apartment, including air samples of 260 particulates SB/M3.
Assessment approach: Comprehensive neurobehavioral toxicity evaluations were performed on 5 occasions two-seven years post-exposure. The assessment included extensive diagnostic interviews, administration of tests which have established normative bases and which are known to be sensitive to neurotoxicity, tests for effort, malingering, distortion, hypochondria, and record review (exposure, medical).
Findings:
Current symptoms: The subject reported the following current symptoms:
Severe cognitive problems
Short term memory loss
Multiple chemical sensitivity (MCS)
Respiratory symptoms on exposure; asthma on extreme exposures
Visual disturbance MCS symptom
Reduced sensation in extremities
Weakness in left hand
Joint pain
Headaches
Sleep Disorder: Sleeps up to 16 hours a day and still fatigued.
Urinary frequency and swelling
The Neurotoxicity Screening Survey (included in Appendix 1) shows a symptom constellation consistent with neurotoxicity in the following categories:
Memory and Concentration
Autonomic Nervous System
Vision
Hearing
Balance
Smell-Taste
Peripheral Numbness
Sensory-Motor
Chemical Sensitivity
Emotionality
Test results:
Blood marker: SB IgE was 51 ELISA units, above the reference range of 50.
Imaging: MRI showed right temporal lobe abnormality.
Electrophysiological testing:
Visual Evoked Potentials: Impression: Visual evoked response study was abnormal bilaterally.
Somatosensory Evoked Potentials: somatosensory evoked potential responses were recorded from each lower extremity by stimulating at the ankle and by recording over the lumbar point and the contralateral sensory cortex. There is prolongation of the absolute latency on the left and borderline on the right. The amplitudes of the waveforms were decreased and poorly developed. Impression: left abnormal due to prolongation at the lumbar plexus and borderline right.
Cognitive function: See Appendix 1. Her Full Scale IQ prior to exposure was estimated to be at the 97 percentile (pct). Initial testing found WAIS-III Working Memory at the 5pct; WMS-III Working Memory 13pct; Selective Reminding Test 11 pct; Comprehensive Trail-Making Test 9pct; Stroop Color and Word Test 7 pct. These results indicate a significant decline in memory and executive function.
Results of the Neurotoxicity Screening Survey were elevated (436) and consistent with neurotoxicity, with Symptom Distortion not indicated.
Repeated testing over 5 years after being removed from exposure found overall cognitive function partially improved, but her function did not return to prior levels.
Personality testing using the NEO Personality Inventory found no significant personality disorder, and did not suggest somatisizing (hypochondria).
Medical record review found no competing explanations of his illness.
See Appendix 1 for a listing of the neurobehavioral test results.
Conclusion: Mold exposure can cause neurotoxicity, revealed by neurobehavioral evaluation, lasting many years after exposure.Appendix 1: Neurobehavioral test results as of 2008
Wechsler Adult Intelligence Scale, Third Edition: WAIS-III:
(In parentheses, under column heading percentile, from tests administered in 2003, 2 years after the exposure began)
Age - Adjusted
Scaled Scores Percentile Classification of change since 2003
Verbal Subscales
Arithmetic 5 5 (02) Some improvement, but still quite deficit
Digit Span 10 50 (16) Improvement, but still deficit for you
Letter-Number
Sequencing 13 84 (16) Improvement
Performance Subscales
Digit Symbol - Coding 9 37 (50) Decrease
Block Design 10 50 (75) Decrease
Object Assembly 10 50 Not previously administered
Object Assembly results are deficit for the subject, showing why she might be having difficulty in directions and getting lost.
Score Percentile Confidence Interval - 90%
Index Scores:
Working Memory 95 37 90 - 101
(5) Improvement
Interpretation: Overall, the subject is still showing cognitive deficits when compared with her pre-exposure level of function. Some functions mildly improved, and some functions declined. Overall memory function as measured by this test improved to the 37th percentile, however, this is still a deficit function for the subject. Mental arithmetic skills are still quite poor.
Wechsler Memory Scale, Third Edition (WMS-III):
Primary Subtests Age Scaled Score Percentile
Logical Memory I - Recall 14 91
Verbal Paired Assoc. I - Recall 10 50
Logical Memory II - Recall 11 63
Verbal Paired Assoc. II - Recall 10 50
Auditory Recognition - Delayed 15 95
Auditory Process Subtests
Logical Memory I
1st Recall Total 13 84
Learning Slope 15 95
Verbal Paired Assoc. I
1st Recall Total 11 63
Learning Slope 11 63
Logical Memory II
Percent Retention 7 25
Verbal Paired Assoc. II
Percent Retention 9 37
Confidence
Primary Index Scores Index Score Percentile Interval (90%)
Auditory Immediate 111 77 104 - 116
(47) Improvement
Auditory Delayed 102 55 94 - 110
(87) Decreased
Auditory Recog. Delayed 125 95 109 - 128
(91) Unchanged
Sum of
Auditory Process Composites Scaled Scores Percentile
Single Trial Learning 24 78
Learning Slope 26 89
Retention 17 25
Retrieval 5 97
Primary Index Differences Frequency of
Difference in
Standardization
Difference Sample
AD - ARD -23 6.9
Interpretation: Declines continue to be found in verbal memory. The primary problem appears to be difficulty in retention of learned material.
Benton Visual Retention Test (Administration B, Form C). This test assesses the ability to remember, based upon visual input. Comparison IQ = 128
Expected for IQ Observed Difference
Number correct 6 8 +2
(7)
Number errors 5 3 -2
(4)
Interpretation: Unchanged
Number Correct Score: Within Normal Limits.
Number of Errors Score: Within Normal Limits.
Benton Visual Retention Test (Administration B, Form C). This test assesses the ability to remember, based upon visual input. Comparison IQ = 128
Results as of 7/27/2004
Expected for IQ Observed Difference
Number correct 6 6 0
Number errors 5 5 0
Interpretation:
Number Correct Score: Within normal limits.
Number of Errors Score: Within normal limits.
The Booklet Category Test
Raw Score T-score Percentile
I Errors 0
II Errors 0
III Errors 4
IV Errors 1
V Errors 9
VI Errors 7
VII Errors 2
Total Errors 23 61 86
Interpretation: Within normal limits. This test was not given previously.
Comprehensive Trail-Making Test (CTMT) comprises a standardized set of five visual search and sequencing tasks that are heavily influenced by attention, concentration, resistance to distraction, and cognitive flexibility, in addition to visual search and sequencing demands. The CTMT may be useful in neuropsychological assessment generally for the purposes of detecting brain compromise... including the detection of frontal lobe deficits; problems with psychomotor speed, visual search and sequencing, and attention; and impairments in set-shifting.
Trail # Raw Score T-Score Percentile Description
1 34 55 69 Average
2 42 52 58 Average
3 53 46 35 Average
4 38 53 62 Average
5 108 39 14 Below Average
(16) Unchanged
Total 245
Composite Index 48 43
(9) Improved
Interpretation: Although there was an improvement in the composite index, in the critical trail number five, the results were unchanged.
Testing: 7/27/04
Trail # Raw Score T-Score Percentile Description
1 39 52 58 Average
2 41 53 62 Average
3 41 55 69 Average
4 31 59 82 Average
5 71 49 46 Average
Total 268
Composite Index 54 67
Interpretation: Showed some improvement compared with prior testing, and post testing.
Controlled Oral Word Association Test evaluates verbal fluency, the ability to find and use words (Benton Controlled Oral Word Association Test: Reliability and updated norms. RM Ruff et al. Archives of Clinical Neuropsychology, 11(4), 329-338, 1996).
Raw Score Correction Total Percentile Classification
31 31 -7 = 24 4.5 Deficient
Interpretation: Previously 21st percentile: decreased
Perseverations: 0
Frontal Systems Behavior Scale (FRSBE) is a rating scale designed to measure behaviors associated with damage to the frontal lobes and frontal systems of the brain.
Self Rating
T-score T-score
Before Illness % After Illness %
Apathy 52 58 94 >99
Disinhibition 71 98 71 98
Executive Dysfunction 56 73% 82 >99
Total 82 >99
Interpretation: Similar as before.
Grooved Pegboard Test evaluates manual dexterity (the ability to use hands in a sensitive and productive way). Dominant Hand:
Dominant Non-dominant
Time for completion: 100 s 88 s
Percentile: 1.4 16
Interpretation: Deficit. Similar as before. Note somatosensory evoked potential abnormalities as described in an above section of this report.
Neitz Test of Color Vision screens for color vision defects.
Number correct of 9 items: 4/9
Interpretation: Moderate Unspecified Deficiency/ Significant Tritan Deficiency
Neurotoxicity Screening Survey:
Factor Results
Score Classification
Memory and Concentration...... 104 Elevated
Autonomic Nervous System...... 71 Elevated
Vision........................ 18 Elevated
Hearing....................... 5 Within Normal Limits
Balance....................... 2 Borderline
Smell-Taste................... 6 Elevated
Peripheral Numbness........... 15 Elevated
Sensory-Motor................. 42 Elevated
Chemical Sensitivity.......... 10 Elevated
Emotionality.................. 45 Elevated
Distortion I.................. 8 Within Normal Limits
Distortion II................. 7 Within Normal Limits
Overall Neurotoxicity Indicator 318 Elevated
Interpretation: Results consistent with those of patients diagnosed with neurotoxicity.
Paced Auditory Serial Addition Test evaluates auditory information processing and tracking.
Subject was unable to perform this test, so the testing was discontinued.
Interpretation: Deficit
Ruff Figural Fluency Test measures nonverbal fluency analogous to the verbal tests that require the respondent to generate as many words as possible starting with a specific letter of the alphabet.
Error Education
Raw Ratio Correction Total Percentile Interpretation
Unique Designs 42 - 7 35 1-5% Impaired
Perseverations 7 0.175 -0.03 0.145 69% Average
Interpretation: Deficit
Selective Reminding Test evaluates the ability to learn. A list of words is read, followed by free recall. After each trial and subsequent recall, the subject is reminded of words that were missed. Twelve trials are administered.
Words continuously remembered, summed over trials (CLTR): 40
Expected: 74.1
Percentile rank for gender, age and education: 15%
Interpretation: Deficit. Previously 11%, similar.
Stroop Color and Word Test evaluates mental flexibility (45 sec administration).
Raw Age/Ed
Score Predicted Residual T-Score Percentile
Word reading: 79 113 -34 26 <1
Color naming: 60 81 -21 33 5
Color/Word: 31 46 -15 35 7
Interference: 31 35 - 4 46 35
Interpretation: Deficit - similar as in the past
Visual Search and Attention Test This test measures visual scanning and sustained attention. The measurement of attentional processes is an important element in the assessment of brain-damaged patients or individuals with suspected cognitive deficits. Attention and concentration are commonly impaired in individuals who have suffered brain damage and impairment in these abilities is often a prominent residual effect of brain damage
Left Right Total
Score 43 36 79
Percentile 25 21 22
Interpretation: Deficit - but improved
EMOTIONAL FUNCTION
Beck Anxiety Inventory measures emotional anxiety*. Score: 22
Interpretation: Moderate Anxiety (Improved)
Beck Depression Inventory measures emotional depression**. Score: 23
Interpretation: Moderate to Severe Depression (Similar)
Profile of Mood States
Raw Score T Score %
Tension 15 44 27
Depression** 18 44 27
Anger/Hostility 6 42 22
Vigor 3 40 16
Fatigue 21 60 84
Confusion/Bewilderment 20 60 84
Interpretation: Not depressed at time of testing. High levels of fatigue and confusion.
WELL-BEING MEASURES
Alcohol Use Disorders Identification Test (AUDIT) was developed by the World Health Organization to identify alcohol use disorders. Cutoff = 8
Score: 1
Interpretation: Alcohol use problems are unlikely.
Fatigue Severity Scale identifies fatigue with features that are specific to the medically ill. These features are largely independent of depressive symptoms of fatigue.
Mean score: 6.1
Interpretation: Consistent with medically ill patients - similar as in past
General Well Being Schedule evaluates general well-being compared with the population of the US.
Score: 45
0-60 Severe Distress
Human Activity Profile measures levels of physical activity.
Score Percentile
Maximum Activity Score 79 71
Adjusted Activity Score 69 33
Activity Age 51
Activity Classification Moderately Active
Dyspnea Scale 7 41
Interpretation: Within Normal Limits
Quick Environmental Exposure and Sensitivity Inventory, Version 1 (QEESI) identifies health problems respondent may experience in response to various environmental exposures.
Score Interpretation
Chemical Intolerance 89 High
Other Intolerance 58 High
Symptom Severity 71 High
Masking Index 1 Low
Life Impact 94 High
Interpretation: Very Suggestive of Multiple Chemical Intolerance. Similar as in past.
DISTORTION AND MALINGERING TESTS
Absurd responding detects a patient responding an nonsensical way.
Results: 0/3
Interpretation: Non-malingering
Dot Counting Test detects suspect test-taking efforts in adults.
Comparison Group: Mild Dementia
Mean Ungrouped Time 7.8
Mean Grouped Time 5.6
Number of errors 1
Signs of suspect effort
Does mean Grouped time exceed mean Ungrouped time by 1 sec? No
Are there counting errors on Card 6 and/or Card 12? No
E-Score (# of errors plus mean time, ungrouped and group) 15
E-Score Cutoff 22
Under test development conditions:
Sensitivity (the test’s ability to detect suspect effort) 62%
Specificity (the test’s ability to detect normal effort) 94%
Under base rate assumption of 15% population suspect effort:
Positive Predictive Accuracy
(the test’s ability to detect suspect effort) 64%
Negative Predictive Accuracy
(the test’s ability to detect normal effort) 93%
Interpretation: Normal effort
Dot Counting Test detects suspect test-taking efforts in adults. Testing: 7/27/04
Comparison Group: Mild Dementia
Mean Ungrouped Time 7.2
Mean Grouped Time 3.2
Number of errors 0
Signs of suspect effort
Does mean Grouped time exceed mean Ungrouped time by 1 sec? No
Are there counting errors on Card 6 and/or Card 12? No
E-Score (# of errors plus mean time, ungrouped and group) 11
E-Score Cutoff 22
Under test development conditions:
Sensitivity (the test’s ability to detect suspect effort) 62%
Specificity (the test’s ability to detect normal effort) 94%
Under base rate assumption of 15% population suspect effort:
Positive Predictive Accuracy
(the test’s ability to detect suspect effort) 64%
Negative Predictive Accuracy
(the test’s ability to detect normal effort) 93%
Interpretation: Normal effort
Miller Forensic Assessment of Symptoms Test (M-FAST) provides information regarding the probability that an individual is malingering psychiatric illness based on a structured interview. Administered 7/27/04. Total score cutoff = 6.
% Negative % Positive
Raw Score Prediction Prediction
Reported vs. Observed 0
Extreme Symptomatology 0
Rare Combinations 0
Unusual Hallucinations 0
Unusual Symptom Course 0
Negative Image 0
Suggestibility 0
Total 0 100% <48%
Interpretation: Honest responder
Three Word Memory Test evaluates the presence of a memory disorder. A malingering subject may remember less than 40% of the words.
Number correct: 12/12
Interpretation: Non-malingering
TOMM
Raw Score
Trial 1 48
Trial 2 50
Retention 50
Interpretation: Good effort
Recognition testing: Recognition is an easier task than recall.
Recognition test*** Results Classification
Logical Memory II 29/30 excellent effort
Verbal Paired Associates II 24/24 word pairs excellent effort
Auditory recognition - Delayed (min 43) 53 good or better effort
Saturday, October 25, 2008
Forensic Evaluation of Neuropsychological Decline Following Solvent Exposure
Forensic Evaluation of Neuropsychological Decline Following Solvent Exposure
Raymond Singer, Ph.D.
Independent Practice
Santa Fe, New Mexico
and
New York, New York
www.neurotox.com
ray.singer@gmail.com
Published until Nov 15 at: http://neurotox.blogspot.com/
Presented at the National Academy of Neuropsychology 28th Annual Meeting, New York City, October 25, 2008.
Objective: Forensic analysis of naphtha-exposed sailor with severe anxiety/depression and personality deterioration. Were his symptoms and illnesses due to acute naphtha workplace exposure?
Case:
Gender: Male
Age at exam: 45
Educational level: 6th grade
Height: 5'9"
Weight: 200
Ethnicity: White
Marital Status: Married but separated
The Chemical Exposure
History of accident: The subject had unloaded 50,000 gallons of naphtha from a tugboat barge the night before the accident, with inhalation exposure. The next day, he was removing the puddles of naphtha from the open tank. Per the first responder Ambulance Report: The subject was found unconscious and unresponsive on a tugboat in a booth in the galley. (The galley is the compartment of a ship, submarine, train or aircraft where food is cooked and prepared).
The crew stated that the patient had unloaded 47,000 barrels of naphtha the night before (from the barge of the tugboat to storage onshore). He had gone to bed, woke in the morning, and started cleaning residue from the hold of the barge. At about 1600 hrs, he went into the galley and told a crew member he felt weak and dizzy, with numbness and tingling of both shoulders. The patient then collapsed.
A crew member stated that he observed that the patient had periods of apnea (cessation of breathing) lasting 11-30 seconds, with breath returning after the crew member shook the patient. When found by the ambulance crew, the patient was unconscious and unresponsive to verbal and painful stimuli.
After an intravenous line was started, the patient complained of shortness of breath and dizziness occurring earlier. The patient stated that he had inhaled much naphtha during cleaning residue from the hold of the barge; that he got some naphtha on his hands; and that he had not worn a respirator.
Neurotoxic hazards of naphtha: Naphtha, AKA petroleum ether, is a well known neurotoxic agent. Acute neurotoxic effects of petroleum ether include anesthesia, euphoria, vertigo, and limb numbness. Note that the subject had all of these acute symptoms (method of clinical diagnosis).
Chronic effects include CNS symptoms of headache, fatigue, poor concentration, emotional instability, impaired memory and other intellectual functions, and impaired psychomotor performance. Neuropsy-chological testing is recommended by medical authorities for this exposure and resulting symptoms.
Medical record review found: Dyspnea, trouble sleeping at night, pulmonary edema due to fumes and vapors, headache, dizziness, and generalized weakness, following his exposure, decreased vital capacity and severe decrease in diffusion capacity of the lungs, probable restricted pulmonary function, organic brain disease, sensory nerve conduction studies of the bilateral trigeminal nerve found bilateral disease; regarding the median nerves, slight abnormality on the left, severe abnormality on the right. Regarding ulnar nerves, slight abnormality on the left, moderate abnormality on the right; lung inflammation; mild restrictive pulmonary function, mildly decreased oxygen level in blood, pulmonary function tests results consistent with restrictive defect, diffuse peripheral neuropathy with axonal degeneration radiculo-neuropathy (bilateral neuropathy of the ulnar nerve across the elbow). He said a hospital diagnosed sleep apnea, but he did not provide those records.
He had never been diagnosed with a psychiatric disorder. He had no prior head or neck injuries, loss of consciousness, chronic headaches or any health problems.
Symptoms: The subject reported: "When I first got hurt, I shut myself up in the rear of my house for a year and a half - I was so depressed, I couldn't get myself off the bed... I shut myself away from everybody for 1- 1.5 years, except for doctors. Everything bothered, annoyed and frustrated me - then I get angry."
"When this first happened, I slept all the time. Now I can't go to sleep. I sleep from 4 - 8 am... If I go to sleep any earlier, I'll awaken in an hour or so and then stay awake."
He now lives in a trailer on grandmother's property- "I don't go nowhere". Prior to his illness, he had renovated his own home, which was on the historical registry. In addition to his home, he owned the property next door, and five properties in Houston - one was commercial. He also owned and managed two taxicab companies, and maintained his own vehicles. He also owned and maintained by himself an antique sports car. When not working, he hunted, fished, swam and danced.
He did not have illnesses before this accident, except pneumonia once, but he kept working anyway.
Since his illness, he lost his cab company, his wife separated from him, and he is a hermit, stating "I don't even go to a picture show... the furthest I go is to a doctor in town, maybe grab a burger and eat on the way home. I live next door to my grandmom, and I rarely go visit her. I get real irritable, I get depressed, with lot of things on my mind, and I don't feel like being around people".
Results: See Appendix 1. Average intelligence was used for comparison purposes. Declines were found in all WAIS-III indices; WMS-III and the SRT found deficits in various memory functions; executive dysfunction was found by declines in word and visual fluency, trailmaking, and visual search and attention test. Emotional function declined with Beck severe anxiety and extremely severe depression. Quick Environmental Exposure and Sensitivity Inventory was highly elevated. Distortion not found, using M-FAST, Boone et al. Dot Counting, Portland Digit Recognition Test, and additional malingering tests. NEO-R found declines in personality, including possible personality disorders (see Appendix 2).
Conclusions: The subject was unaware of his cognitive decline, yet testing showed clear declines from prior levels of neuropsychological function, with emotional and personality deterioration caused by acute naphtha exposure.
Appendix 1: Results
Wechsler Adult Intelligence Scale, Third Edition: WAIS-III:
Age - Adjusted
Scaled Scores Percentile
Verbal Subscales
Vocabulary 6 9%
Similarities 7 16%
Arithmetic 7 16%
Digit Span 5 5%
Information 7 16%
Comprehension 10 50%
Letter-Number
Sequencing 9 37%
Performance Subscales
Picture Completion 6 9%
Digit Symbol - Coding 4 2%
Block Design 8 25%
Matrix Reasoning 7 16%
Picture Arrangement 10 50%
Symbol Search 3 1%
Object Assembly 7 16%
Score Percentile Confidence Interval - 90%
IQ Scores:
Verbal IQ: 82 12% 78 - 87
Performance IQ: 80 9% 76 - 87
Full Scale IQ: 79 8% 76 - 83
Index Scores:
Verbal Comprehension 82 12% 78 - 87
Perceptual Organization 82 12% 77 - 89
Working Memory 82 12% 77 - 89
Processing Speed 68 2% 64 - 79
Interpretation: Deficit in all indexes of cognitive function.
Wechsler Memory Scale, Third Edition (WMS-III):
Primary Subtests Age Scaled Score Percentile
Logical Memory I - Recall 5 5%
Faces I - Recognition 7 16%
Verbal Paired Assoc. I - Recall 7 16%
Family Pictures I - Recall 8 25%
Letter-Number Sequencing 9 37%
Spatial Span 8 25%
Logical Memory II - Recall 7 16%
Faces II - Recognition 9 37%
Verbal Paired Assoc. II - Recall 6 9%
Family Pictures II - Recall 8 25%
Auditory Recognition - Delayed 6 9%
Auditory Process Subtests
Logical Memory I
1st Recall Total 5 5%
Learning Slope 11 63%
Verbal Paired Assoc. I
1st Recall Total 7 16%
Learning Slope 8 25%
Logical Memory II
Percent Retention 9 37%
Verbal Paired Assoc. II
Percent Retention 6 9%
Confidence
Primary Index Scores Index Score Percentile Interval (90%)
Auditory Immediate 77 6% 73 - 84
Visual Immediate 84 14% 78 - 95
Immediate Memory 76 5% 71 - 85
Auditory Delayed 80 9% 75 - 90
Visual Delayed 91 27% 84 - 101
Auditory Recog. Delayed 80 9% 76 - 95
General Memory 81 10% 76 - 89
Working Memory 91 27% 84 - 100
Sum of
Auditory Process Composites Scaled Scores Percentile
Single Trial Learning 12 3%
Learning Slope 19 44%
Retention 15 15%
Retrieval -1 34%
Interpretation: Deficit in auditory and immediate memory.
Comprehensive Trail-Making Test (CTMT)
Trail # Raw Score T-Score Percentile Description
1 70 29 2%
2 96 24 <1%
3 96 25 <1%
4 131 18 <1% *Note: patient made 2 mistakes.
5 112 28 1% *Note: patient made 1 mistake.
Total 124
Composite Index 22 1%
Interpretation: Deficit in executive function.
Controlled Oral Word Association Test
Raw Score Correction Total Percentile Classification
20 +3 23 4% Deficient
Interpretation: Deficit
Perseverations: 0 56% Intact
Embedded Figures Test:
Number detected out of 40 objects: 28 Percentile for age and education: 23% Interpretation: Within normal limits
Grooved Pegboard Test evaluates manual dexterity (the ability to use hands in a sensitive and productive way). Dominant Hand: Right
Dominant Non-dominant
Time for completion: 98" 113"
Percentile: 7% 1%
Interpretation: Deficit Deficit
Neurotoxicity Screening Survey:
Factor Results
Score Classification
Memory and Concentration...... 133 Elevated
Autonomic Nervous System...... 95 Elevated
Vision........................ 30 Elevated
Hearing....................... 14 Elevated
Balance....................... 5 Elevated
Smell-Taste................... 12 Elevated
Peripheral Numbness........... 34 Elevated
Sensory-Motor................. 74 Elevated
Chemical Sensitivity.......... 6 Elevated
Emotionality.................. 77 Elevated
Distortion I.................. 13 Within Normal Limits
Distortion II................. 16 Within Normal Limits
Overall Neurotoxicity Indicator: 480 Elevated
Interpretation: Results consistent with those of patients diagnosed with neurotoxicity.
Paced Auditory Serial Addition Test Note: Patient did not complete because he could not understand the instructions. Interpretation: Deficit
Ruff Figural Fluency Test
Error Education
Raw Ratio Correction Total Percentile Interpretation
Unique Designs 41 +12 53 2.3% Impaired
Perseverations 9 0.2195 -0.03 0.1895 84.1% Low Average
Interpretation: Deficit in executive function.
Selective Reminding Test
Words continuously remembered, summed over trials (CLTR): 33
Expected: 78.9
Percentile rank for gender, age and education: 12%
Interpretation: Deficit
Stroop Color and Word Test evaluates mental flexibility (45 sec administration).
Raw Age/Ed
Score Predicted Residual T-Score Percentile Interpretation
Word reading: 64 87 -23 34 6% Deficit
Color naming: 56 69 -13 39 14% Within normal limits
Color/Word: 22 30 - 8 42 21% Within normal limits
Interference: 22 31 - 9 41 18% Within normal limits
Visual Search and Attention Test
Left Right Total
Score 35 28 63
Percentile 1% 1% 1%
Interpretation: Deficit Deficit Deficit
Wide Range Achievement Test
SS Percentile Grade Equiv. Classification
Reading 62 1% 3rd Grade
Spelling 57 <1% 2nd Grade
Arithmetic 77 6% 5th Grade
Interpretation: Deficit
EMOTIONAL FUNCTION
Beck Anxiety Inventory. Score: 33 Interpretation: Severe anxiety
Beck Depression Inventory. Score: 35. Interpretation: Extremely severe depression
Profile of Mood States
Raw Score T Score %
Tension 30 63 90%
Depression** 40 62 89%
Anger/Hostility 42 78 79%
Vigor 6 42 21%
Fatigue 22 66 95%
Confusion/Bewilderment 15 54 66%
Interpretation: Showed moods of tension, depression, anger, and fatigue.
Psychiatric Diagnostic Interview - Revised screens for Organic Brain Syndrome. Interpretation: Impaired.
Whitaker Inventory of Schizophrenic Thinking Index: 22
Interpretation: Intermediate probability of schizophrenic thinking.
WELL-BEING MEASURES
Alcohol Use Disorders Identification Test (AUDIT) was developed by the World Health Organization to identify alcohol use disorders. Cutoff = 8
Score: 0 Interpretation: Alcohol use problems are unlikely.
Fatigue Severity Scale identifies fatigue with features that are specific to the medically ill. These features are largely independent of depressive symptoms of fatigue.
Mean score: 7 Interpretation: Consistent with medically ill patients
General Well Being Schedule evaluates general well-being compared with the population of the US.
Score: Severe Distress
Human Activity Profile measures levels of physical activity.
Score Percentile
Maximum Activity Score 57 <1%
Adjusted Activity Score 31 <1%
Activity Age 70+
Activity Classification Impaired
Dyspnea Scale 2 52%
Interpretation: Deficit
Quick Environmental Exposure and Sensitivity Inventory, Version 1 (QEESI) identifies health problems respondent may experience in response to various environmental exposures.
Score Interpretation
Chemical Intolerance 66 High
Other Intolerance 33 High
Symptom Severity 85 High
Masking Index 4 Medium
Life Impact 64 High
Interpretation: Very suggestive of multiple chemical intolerance.
DISTORTION AND MALINGERING TESTS
Absurd responding checks for very unusual responses, suggestive of malingering or a psychiatric disorder. Subject passed this test.
Amnesia Questionnaire assesses the subject's possible mis-reporting memory symptoms.
Number correct of 14: 12 Interpretation: Non-malingering
Dot Counting Test detects suspect test-taking efforts in adults. This respondent's answers were compared to the Head Injury normative sample in a medico-legal neuropsychological assessment environment.
Comparison Group: Mild Dementia
E-Score: 10 E-Score Cutoff: 22
Signs of suspect effort
Does mean Grouped time exceed mean Ungrouped time by 1 sec? No
Are there counting errors on Card 6 and/or Card 12? No
Interpretation: Normal Effort
Endorsement of Rare Symptoms. The Neurotoxicity Screening Survey presents 14 symptoms that are rare. If a number of these symptoms are endorsed, the question of distortion is highlighted.
Number endorsed: Distortion I: 2 Distortion II: 3 Interpretation: Non-malingering
Even-Odd Forced Choice Test requires the subject to add two single digit numbers, and determine whether the product is even or odd. If the subject's performance is random, the results will still be approximately the same as the results of someone performing absolutely correctly.
Number correct: 19/20 Interpretation: Non-malingering
Memorization of "16" Items (Iverson & Franzen, 1991) requires the subject to memorize a list of 16 items. Because the 16 items are grouped into four conceptual categories, the task is easier than it looks. A cutoff of 6 is used to suggest malingering.
Number correct: 16/16 Interpretation: Non-malingering
Miller Forensic Assessment of Symptoms Test (M-FAST)
Raw Score
Reported vs. Observed 0
Extreme Symptomatology 1
Rare Combinations 0
Unusual Hallucinations 1
Unusual Symptom Course 0
Negative Image 1
Suggestibility 0
Total 3
Interpretation: Within normal limits
Portland Digit Recognition Test
Percent correct responses (5 sec delay): 5/8
Percent correct responses (15 sec delay): 5/7
Percent correct responses (30 sec delay): 5/5
Interpretation: Non-malingering
Three Word Memory Test Number correct: 13/13 trials Interpretation: Non-malingering
Twenty-one Item Memory Test
Number of words correctly recalled:
Free recall: 3
Forced choice: 11
Interpretation: Non-malingering
Recognition testing: Recognition is an easier task than recall.
Recognition tests*** Results Classification
Logical Memory II
24/30
good or better effort
Verbal Paired Associates II
19/24 word pairs
acceptable effort
Word Lists II (min. 18)
15/24
severe brain damage or poor effort
Visual Reproduction II
43/48
excellent effort
Auditory recognition - Delayed (min 43)
43/48
excellent effort
Appendix 2: NEO Personality Testing
Validity indices are within normal limits.
The subject is experiencing a high level of negative emotion and frequent episodes of psychological distress. He is moody, overly sensitive, and dissatisfied with many aspects of his life. He is low in self-esteem. He is a worrier.
The subject is quite introverted, quiet and reserved regarding group interactions. He rarely experiences joy or excitement. He would be described as reserved, serious, retiring and a loner.
The subject has a strong preference for the familiar and pragmatic. He likes routine, is set in his ways, with little desire for change in himself or his world. His respect for authority and his reluctance to question established values may make him a defender of tradition. He is down to earth, conforming, unadventurous, and conventional.
The subject at times can be antagonistic, brusque, and even possibly rude. He can be described as relatively stubborn and critical.
Apparently since his illness, the subject has a low need for a achievement, lack of self-discipline, is unreliable and careless.
The subject can be described as aloof, reserved, arrogant, cold and unfeeling.
Possible personality disorders: Borderline features or a Borderline Personality Disorder; Antisocial Personality Disorder; Narcissistic Personality Disorder; Avoidant Personality Disorder; and Obsessive-Compulsive Disorder.
Raymond Singer, Ph.D.
Independent Practice
Santa Fe, New Mexico
and
New York, New York
www.neurotox.com
ray.singer@gmail.com
Published until Nov 15 at: http://neurotox.blogspot.com/
Presented at the National Academy of Neuropsychology 28th Annual Meeting, New York City, October 25, 2008.
Objective: Forensic analysis of naphtha-exposed sailor with severe anxiety/depression and personality deterioration. Were his symptoms and illnesses due to acute naphtha workplace exposure?
Case:
Gender: Male
Age at exam: 45
Educational level: 6th grade
Height: 5'9"
Weight: 200
Ethnicity: White
Marital Status: Married but separated
The Chemical Exposure
History of accident: The subject had unloaded 50,000 gallons of naphtha from a tugboat barge the night before the accident, with inhalation exposure. The next day, he was removing the puddles of naphtha from the open tank. Per the first responder Ambulance Report: The subject was found unconscious and unresponsive on a tugboat in a booth in the galley. (The galley is the compartment of a ship, submarine, train or aircraft where food is cooked and prepared).
The crew stated that the patient had unloaded 47,000 barrels of naphtha the night before (from the barge of the tugboat to storage onshore). He had gone to bed, woke in the morning, and started cleaning residue from the hold of the barge. At about 1600 hrs, he went into the galley and told a crew member he felt weak and dizzy, with numbness and tingling of both shoulders. The patient then collapsed.
A crew member stated that he observed that the patient had periods of apnea (cessation of breathing) lasting 11-30 seconds, with breath returning after the crew member shook the patient. When found by the ambulance crew, the patient was unconscious and unresponsive to verbal and painful stimuli.
After an intravenous line was started, the patient complained of shortness of breath and dizziness occurring earlier. The patient stated that he had inhaled much naphtha during cleaning residue from the hold of the barge; that he got some naphtha on his hands; and that he had not worn a respirator.
Neurotoxic hazards of naphtha: Naphtha, AKA petroleum ether, is a well known neurotoxic agent. Acute neurotoxic effects of petroleum ether include anesthesia, euphoria, vertigo, and limb numbness. Note that the subject had all of these acute symptoms (method of clinical diagnosis).
Chronic effects include CNS symptoms of headache, fatigue, poor concentration, emotional instability, impaired memory and other intellectual functions, and impaired psychomotor performance. Neuropsy-chological testing is recommended by medical authorities for this exposure and resulting symptoms.
Medical record review found: Dyspnea, trouble sleeping at night, pulmonary edema due to fumes and vapors, headache, dizziness, and generalized weakness, following his exposure, decreased vital capacity and severe decrease in diffusion capacity of the lungs, probable restricted pulmonary function, organic brain disease, sensory nerve conduction studies of the bilateral trigeminal nerve found bilateral disease; regarding the median nerves, slight abnormality on the left, severe abnormality on the right. Regarding ulnar nerves, slight abnormality on the left, moderate abnormality on the right; lung inflammation; mild restrictive pulmonary function, mildly decreased oxygen level in blood, pulmonary function tests results consistent with restrictive defect, diffuse peripheral neuropathy with axonal degeneration radiculo-neuropathy (bilateral neuropathy of the ulnar nerve across the elbow). He said a hospital diagnosed sleep apnea, but he did not provide those records.
He had never been diagnosed with a psychiatric disorder. He had no prior head or neck injuries, loss of consciousness, chronic headaches or any health problems.
Symptoms: The subject reported: "When I first got hurt, I shut myself up in the rear of my house for a year and a half - I was so depressed, I couldn't get myself off the bed... I shut myself away from everybody for 1- 1.5 years, except for doctors. Everything bothered, annoyed and frustrated me - then I get angry."
"When this first happened, I slept all the time. Now I can't go to sleep. I sleep from 4 - 8 am... If I go to sleep any earlier, I'll awaken in an hour or so and then stay awake."
He now lives in a trailer on grandmother's property- "I don't go nowhere". Prior to his illness, he had renovated his own home, which was on the historical registry. In addition to his home, he owned the property next door, and five properties in Houston - one was commercial. He also owned and managed two taxicab companies, and maintained his own vehicles. He also owned and maintained by himself an antique sports car. When not working, he hunted, fished, swam and danced.
He did not have illnesses before this accident, except pneumonia once, but he kept working anyway.
Since his illness, he lost his cab company, his wife separated from him, and he is a hermit, stating "I don't even go to a picture show... the furthest I go is to a doctor in town, maybe grab a burger and eat on the way home. I live next door to my grandmom, and I rarely go visit her. I get real irritable, I get depressed, with lot of things on my mind, and I don't feel like being around people".
Results: See Appendix 1. Average intelligence was used for comparison purposes. Declines were found in all WAIS-III indices; WMS-III and the SRT found deficits in various memory functions; executive dysfunction was found by declines in word and visual fluency, trailmaking, and visual search and attention test. Emotional function declined with Beck severe anxiety and extremely severe depression. Quick Environmental Exposure and Sensitivity Inventory was highly elevated. Distortion not found, using M-FAST, Boone et al. Dot Counting, Portland Digit Recognition Test, and additional malingering tests. NEO-R found declines in personality, including possible personality disorders (see Appendix 2).
Conclusions: The subject was unaware of his cognitive decline, yet testing showed clear declines from prior levels of neuropsychological function, with emotional and personality deterioration caused by acute naphtha exposure.
Appendix 1: Results
Wechsler Adult Intelligence Scale, Third Edition: WAIS-III:
Age - Adjusted
Scaled Scores Percentile
Verbal Subscales
Vocabulary 6 9%
Similarities 7 16%
Arithmetic 7 16%
Digit Span 5 5%
Information 7 16%
Comprehension 10 50%
Letter-Number
Sequencing 9 37%
Performance Subscales
Picture Completion 6 9%
Digit Symbol - Coding 4 2%
Block Design 8 25%
Matrix Reasoning 7 16%
Picture Arrangement 10 50%
Symbol Search 3 1%
Object Assembly 7 16%
Score Percentile Confidence Interval - 90%
IQ Scores:
Verbal IQ: 82 12% 78 - 87
Performance IQ: 80 9% 76 - 87
Full Scale IQ: 79 8% 76 - 83
Index Scores:
Verbal Comprehension 82 12% 78 - 87
Perceptual Organization 82 12% 77 - 89
Working Memory 82 12% 77 - 89
Processing Speed 68 2% 64 - 79
Interpretation: Deficit in all indexes of cognitive function.
Wechsler Memory Scale, Third Edition (WMS-III):
Primary Subtests Age Scaled Score Percentile
Logical Memory I - Recall 5 5%
Faces I - Recognition 7 16%
Verbal Paired Assoc. I - Recall 7 16%
Family Pictures I - Recall 8 25%
Letter-Number Sequencing 9 37%
Spatial Span 8 25%
Logical Memory II - Recall 7 16%
Faces II - Recognition 9 37%
Verbal Paired Assoc. II - Recall 6 9%
Family Pictures II - Recall 8 25%
Auditory Recognition - Delayed 6 9%
Auditory Process Subtests
Logical Memory I
1st Recall Total 5 5%
Learning Slope 11 63%
Verbal Paired Assoc. I
1st Recall Total 7 16%
Learning Slope 8 25%
Logical Memory II
Percent Retention 9 37%
Verbal Paired Assoc. II
Percent Retention 6 9%
Confidence
Primary Index Scores Index Score Percentile Interval (90%)
Auditory Immediate 77 6% 73 - 84
Visual Immediate 84 14% 78 - 95
Immediate Memory 76 5% 71 - 85
Auditory Delayed 80 9% 75 - 90
Visual Delayed 91 27% 84 - 101
Auditory Recog. Delayed 80 9% 76 - 95
General Memory 81 10% 76 - 89
Working Memory 91 27% 84 - 100
Sum of
Auditory Process Composites Scaled Scores Percentile
Single Trial Learning 12 3%
Learning Slope 19 44%
Retention 15 15%
Retrieval -1 34%
Interpretation: Deficit in auditory and immediate memory.
Comprehensive Trail-Making Test (CTMT)
Trail # Raw Score T-Score Percentile Description
1 70 29 2%
2 96 24 <1%
3 96 25 <1%
4 131 18 <1% *Note: patient made 2 mistakes.
5 112 28 1% *Note: patient made 1 mistake.
Total 124
Composite Index 22 1%
Interpretation: Deficit in executive function.
Controlled Oral Word Association Test
Raw Score Correction Total Percentile Classification
20 +3 23 4% Deficient
Interpretation: Deficit
Perseverations: 0 56% Intact
Embedded Figures Test:
Number detected out of 40 objects: 28 Percentile for age and education: 23% Interpretation: Within normal limits
Grooved Pegboard Test evaluates manual dexterity (the ability to use hands in a sensitive and productive way). Dominant Hand: Right
Dominant Non-dominant
Time for completion: 98" 113"
Percentile: 7% 1%
Interpretation: Deficit Deficit
Neurotoxicity Screening Survey:
Factor Results
Score Classification
Memory and Concentration...... 133 Elevated
Autonomic Nervous System...... 95 Elevated
Vision........................ 30 Elevated
Hearing....................... 14 Elevated
Balance....................... 5 Elevated
Smell-Taste................... 12 Elevated
Peripheral Numbness........... 34 Elevated
Sensory-Motor................. 74 Elevated
Chemical Sensitivity.......... 6 Elevated
Emotionality.................. 77 Elevated
Distortion I.................. 13 Within Normal Limits
Distortion II................. 16 Within Normal Limits
Overall Neurotoxicity Indicator: 480 Elevated
Interpretation: Results consistent with those of patients diagnosed with neurotoxicity.
Paced Auditory Serial Addition Test Note: Patient did not complete because he could not understand the instructions. Interpretation: Deficit
Ruff Figural Fluency Test
Error Education
Raw Ratio Correction Total Percentile Interpretation
Unique Designs 41 +12 53 2.3% Impaired
Perseverations 9 0.2195 -0.03 0.1895 84.1% Low Average
Interpretation: Deficit in executive function.
Selective Reminding Test
Words continuously remembered, summed over trials (CLTR): 33
Expected: 78.9
Percentile rank for gender, age and education: 12%
Interpretation: Deficit
Stroop Color and Word Test evaluates mental flexibility (45 sec administration).
Raw Age/Ed
Score Predicted Residual T-Score Percentile Interpretation
Word reading: 64 87 -23 34 6% Deficit
Color naming: 56 69 -13 39 14% Within normal limits
Color/Word: 22 30 - 8 42 21% Within normal limits
Interference: 22 31 - 9 41 18% Within normal limits
Visual Search and Attention Test
Left Right Total
Score 35 28 63
Percentile 1% 1% 1%
Interpretation: Deficit Deficit Deficit
Wide Range Achievement Test
SS Percentile Grade Equiv. Classification
Reading 62 1% 3rd Grade
Spelling 57 <1% 2nd Grade
Arithmetic 77 6% 5th Grade
Interpretation: Deficit
EMOTIONAL FUNCTION
Beck Anxiety Inventory. Score: 33 Interpretation: Severe anxiety
Beck Depression Inventory. Score: 35. Interpretation: Extremely severe depression
Profile of Mood States
Raw Score T Score %
Tension 30 63 90%
Depression** 40 62 89%
Anger/Hostility 42 78 79%
Vigor 6 42 21%
Fatigue 22 66 95%
Confusion/Bewilderment 15 54 66%
Interpretation: Showed moods of tension, depression, anger, and fatigue.
Psychiatric Diagnostic Interview - Revised screens for Organic Brain Syndrome. Interpretation: Impaired.
Whitaker Inventory of Schizophrenic Thinking Index: 22
Interpretation: Intermediate probability of schizophrenic thinking.
WELL-BEING MEASURES
Alcohol Use Disorders Identification Test (AUDIT) was developed by the World Health Organization to identify alcohol use disorders. Cutoff = 8
Score: 0 Interpretation: Alcohol use problems are unlikely.
Fatigue Severity Scale identifies fatigue with features that are specific to the medically ill. These features are largely independent of depressive symptoms of fatigue.
Mean score: 7 Interpretation: Consistent with medically ill patients
General Well Being Schedule evaluates general well-being compared with the population of the US.
Score: Severe Distress
Human Activity Profile measures levels of physical activity.
Score Percentile
Maximum Activity Score 57 <1%
Adjusted Activity Score 31 <1%
Activity Age 70+
Activity Classification Impaired
Dyspnea Scale 2 52%
Interpretation: Deficit
Quick Environmental Exposure and Sensitivity Inventory, Version 1 (QEESI) identifies health problems respondent may experience in response to various environmental exposures.
Score Interpretation
Chemical Intolerance 66 High
Other Intolerance 33 High
Symptom Severity 85 High
Masking Index 4 Medium
Life Impact 64 High
Interpretation: Very suggestive of multiple chemical intolerance.
DISTORTION AND MALINGERING TESTS
Absurd responding checks for very unusual responses, suggestive of malingering or a psychiatric disorder. Subject passed this test.
Amnesia Questionnaire assesses the subject's possible mis-reporting memory symptoms.
Number correct of 14: 12 Interpretation: Non-malingering
Dot Counting Test detects suspect test-taking efforts in adults. This respondent's answers were compared to the Head Injury normative sample in a medico-legal neuropsychological assessment environment.
Comparison Group: Mild Dementia
E-Score: 10 E-Score Cutoff: 22
Signs of suspect effort
Does mean Grouped time exceed mean Ungrouped time by 1 sec? No
Are there counting errors on Card 6 and/or Card 12? No
Interpretation: Normal Effort
Endorsement of Rare Symptoms. The Neurotoxicity Screening Survey presents 14 symptoms that are rare. If a number of these symptoms are endorsed, the question of distortion is highlighted.
Number endorsed: Distortion I: 2 Distortion II: 3 Interpretation: Non-malingering
Even-Odd Forced Choice Test requires the subject to add two single digit numbers, and determine whether the product is even or odd. If the subject's performance is random, the results will still be approximately the same as the results of someone performing absolutely correctly.
Number correct: 19/20 Interpretation: Non-malingering
Memorization of "16" Items (Iverson & Franzen, 1991) requires the subject to memorize a list of 16 items. Because the 16 items are grouped into four conceptual categories, the task is easier than it looks. A cutoff of 6 is used to suggest malingering.
Number correct: 16/16 Interpretation: Non-malingering
Miller Forensic Assessment of Symptoms Test (M-FAST)
Raw Score
Reported vs. Observed 0
Extreme Symptomatology 1
Rare Combinations 0
Unusual Hallucinations 1
Unusual Symptom Course 0
Negative Image 1
Suggestibility 0
Total 3
Interpretation: Within normal limits
Portland Digit Recognition Test
Percent correct responses (5 sec delay): 5/8
Percent correct responses (15 sec delay): 5/7
Percent correct responses (30 sec delay): 5/5
Interpretation: Non-malingering
Three Word Memory Test Number correct: 13/13 trials Interpretation: Non-malingering
Twenty-one Item Memory Test
Number of words correctly recalled:
Free recall: 3
Forced choice: 11
Interpretation: Non-malingering
Recognition testing: Recognition is an easier task than recall.
Recognition tests*** Results Classification
Logical Memory II
24/30
good or better effort
Verbal Paired Associates II
19/24 word pairs
acceptable effort
Word Lists II (min. 18)
15/24
severe brain damage or poor effort
Visual Reproduction II
43/48
excellent effort
Auditory recognition - Delayed (min 43)
43/48
excellent effort
Appendix 2: NEO Personality Testing
Validity indices are within normal limits.
The subject is experiencing a high level of negative emotion and frequent episodes of psychological distress. He is moody, overly sensitive, and dissatisfied with many aspects of his life. He is low in self-esteem. He is a worrier.
The subject is quite introverted, quiet and reserved regarding group interactions. He rarely experiences joy or excitement. He would be described as reserved, serious, retiring and a loner.
The subject has a strong preference for the familiar and pragmatic. He likes routine, is set in his ways, with little desire for change in himself or his world. His respect for authority and his reluctance to question established values may make him a defender of tradition. He is down to earth, conforming, unadventurous, and conventional.
The subject at times can be antagonistic, brusque, and even possibly rude. He can be described as relatively stubborn and critical.
Apparently since his illness, the subject has a low need for a achievement, lack of self-discipline, is unreliable and careless.
The subject can be described as aloof, reserved, arrogant, cold and unfeeling.
Possible personality disorders: Borderline features or a Borderline Personality Disorder; Antisocial Personality Disorder; Narcissistic Personality Disorder; Avoidant Personality Disorder; and Obsessive-Compulsive Disorder.
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