Case Study: Appearance And Behavior

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DAILY ACTIVITIES

Daily, the claimant spends a lot of his time sitting. He sometimes will visit with his mother when his stepfather is not around. He tries to find places to go, so that he can watch television and get warm. He tries to eat regular meals. He says that he socializes, most days. He socializes with family members, AA/NA members and other friends. He goes to AA/NA meetings, visits his mother and visits his brother. He is responsible for cooking his own meals. His mother is responsible for any shopping needs that he may have. He is able to complete these tasks, but asserts that he does not like being around crowds.

MENTAL STATUS

Appearance and Behavior

The claimant wore a T-shirt and a denim jacket to his appointment today. He
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He attended high school through the ninth grade. He received his GED in 1997. He briefly worked for a friend at a pallet company. When he shot a nail into a broken pallet, the nail ricocheted and pierced his left eye, causing blindness. He reported short term memory problems and he needs complex directions to be repeated. Complex instructions are problematic for the claimant. The claimant is impaired in following directions.

Describe the claimant’s abilities and limitations in maintaining attention and concentration, and in maintaining persistence and pace, to perform simple tasks and to perform multi-step tasks.

The claimant had difficulty today concentrating. He was only able to remember three series of digits during the backward recall task. He reports past, work related issues with concentration. He is easily distracted, unable to multitask and begins, but does not finish tasks due to getting sidetracked. Mental health issues that affect his concentration include anxiety and depression. Bipolar disorder with manic mood and racing thoughts distract his ability to focus. The claimant is impaired in
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His bipolar disorder, substance abuse by self, father encouraged disturbed behavior and incarcerations have also affected his work history and behavior. Due to his bipolar disorder, chronic substance use history, neglect by father figures, PTSD and physical medical issues, the claimant is unable to work, to judge and concentrate sufficiently in order to manage the demands of a work environment. The claimant is impaired in following directions, concentration, interpersonal functioning and stress

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