January 1, 2016
Honorable James T. Kirk, Judge
County Probate Court
123 Court Street
Anytown, CA 12345
RE: Sue Jones
CASE NUMBER: 2016-GI-00000
Mental health evaluation
Dear Judge Kirk:
Sue Jones is a 52 year old Caucasian female who was referred by the Court for a guardianship evaluation.
Dr. Betty Rubble interviewed Ms. Jones at Anytown Nursing Home on January 1, 2016 for approximately 105 minutes. She was administered the Independent Living Scales on that date.
Prior to the commencement of this evaluation and psychological testing, Ms. Jones was advised of the nature and purpose of the evaluation. Ms. Jones was informed that the resulting report was not confidential, and that information obtained could be included in the report that would be submitted to the Court. She was aware this information was not related to treatment, but rather for her current case. Ms. Jones was provided this information both orally and in a written format. She stated that she understood the information provided to her, including the limits of confidentiality and her rights concerning the evaluation.
SOURCES OF INFORMATION:
- Collateral contact with Wilma Flintstone, Ms. Jones’ legal guardian, via telephone on January 1, 2016.
- General Hospital, psychiatric records.
- Guardianship Services records.
SOCIAL HISTORY: Ms. Jones reported that she was born on January 1, 1963 and reared in Kentucky. She said her father worked as a security guard and died eight years ago, while her mother worked as a waitress and died five years ago. She identified having a “good” relationship with her parents. Ms. Jones said she has two brothers with whom she has an “all right” relationship, as well as one older maternal half sister that she “[doesn’t ] get along with at all.” Ms. Jones stated that one of her brother has been diagnosed with bipolar disorder, and noted her brothers and her father had difficulties with alcoholism. She denied any childhood history of abuse and reported that she ran away from home at 17 years of age when she became pregnant.
Ms. Jones reported that she lived independently until two years ago when she was placed in a nursing home. She said she remains in a nursing home against her will because the court has appointed her a legal guardian due to her alcoholism. She would like to return to her home of Nowhere, California, where her cousin lives. She said that she talks with her cousin regularly on the phone, but acknowledged that she has not seen her in many years. She does not want a guardian and would like to make her own decisions.
According to her legal guardian, Ms. Flintstone, prior to her nursing-home placement, Ms. Jones was in sober housing. That home had staff present on site, but Ms. Jones continued to drink alcohol and visit hospital emergency rooms to obtain opiates.
EDUCATION HISTORY: Ms. Jones stated that she last completed the 9th grade and had “all right” grades. She said that she was not diagnosed with any learning disabilities, but offered, “I skipped school a lot.” She denied receiving any further education.
WORK AND MILITARY HISTORY: Ms. Jones denied any military history. She said she has held “quite a few jobs,” including positions as a waitress, factory worker, and convenience-store manager. She said her longest position was the convenience-store job, which lasted for three years. Ms. Jones indicated she was never fired from any jobs. She estimated she most recently worked 20 years ago. She has received SSDI benefits for at least 20 years for being “bipolar” and “schizophrenic.” Ms. Jones indicated she has a payee to manage her finances, and she does not mind having one.
RELATIONSHIP HISTORY: Ms. Jones has been married once and is currently divorced. She indicated she “ran away” to New York with a boyfriend at 17 years of age because she was pregnant. She ultimately had an abortion and was unable to bear children thereafter. Ms. Jones was married from 1982 to 1992. Her husband worked as a contractor. She said they divorced because he was “always in jail.” Her most recent romantic relationship was “five years ago.” She indicated she left that man because “we argued a lot” and he engaged in domestic violence against her. Ms. Jones said she is not dating at this time.
SUBSTANCE USE HISTORY: Ms. Jones reported that she first drank alcohol at 16 years of age, during which time she drank on “weekends.” She said her heaviest use of alcohol occurred in her 30’s and 40’s, during which time she drank a “30-pack” of beer daily. She offered, “I’m an alcoholic,” but indicated she has been sober for the past three years that she has been in nursing homes. Ms. Jones reported that she developed tolerance to alcohol, experienced withdrawal symptoms when she could not drink, craved alcohol, gave up important activities to drink, had difficulty controlling her alcohol use, frequently drove a vehicle under the influence of alcohol, and continued to drink despite the legal and financial problems it caused her.
Ms. Jones said that she first used marijuana at 16 years of age, during which time she used that substance once every few weeks. She said her heaviest use of marijuana was in her 40’s, when she used marijuana daily. She stated that she last used marijuana three years ago. Ms. Jones reported that she gave up important activities to use marijuana and frequently drove a vehicle under the influence of marijuana, but otherwise denied any problems associated with her use of that substance.
Ms. Jones reported that she began using crack cocaine in her 40’s, when she used that substance a “couple times a week.” Again, she indicated she stopped using that substance three years ago. Ms. Jones reported that she developed tolerance to cocaine, craved it, had difficulty controlling her use of that substance, spent a great deal of time involved in activities related to her cocaine use, gave up important activities to use cocaine, frequently drove a vehicle under the influence of cocaine, and continued to use it despite the financial problems it caused her.
Ms. Jones indicated that she began abusing her Percocet prescription in her 40’s. She said that whenever she ran out, she bought more off the street. She estimated that she took four to five pills per day. Ms. Jones reported that she gave up important activities to use opiates and frequently drove a vehicle under the influence of opiates, but otherwise denied experiencing any difficulties related to her use of opiates.
With regard to substance-abuse treatment, Ms. Jones said she received inpatient treatment due to her alcohol dependence in her 30’s. When asked how she would prevent substance relapse if in the community, Ms. Jones replied, “I’d plan on going to meetings” and get a “sponsor.” When asked how she would attend such meetings, she responded, “Have someone pick me up.” When asked who might be able to do so, she replied, “I don’t know,” but possibly “friends” or other people in Alcoholics Anonymous.
LEGAL HISTORY: Ms. Jones denied any juvenile legal history. She reported that as an adult, she was convicted of “Petty Theft” once after she stole a candy bar from a store and ate it in front of the clerk because “I was trying to go to jail to see him” (her husband). Ms. Jones indicated she also has one “DUI” conviction as well.
MEDICAL HISTORY: Ms. Jones reported that she cannot walk due to neuropathy related to diabetes. She said she also has COPD, cirrhosis of the liver, and cancer in her left kidney. She could not recall all of her current medications, except that she takes ibuprofen for pain related to cancer and insulin for diabetes. She denied any history of seizure, stroke, coma, or traumatic brain injury. Ms. Jones identified her only surgeries as a tonsillectomy and an appendectomy.
Records from General Hospital indicate Ms. Jones has cirrhosis of the liver, COPD, diabetes mellitus type II, hypercholesterolemia, hypothyroidism, GERD, hyperlipidemia, pulmonary disease, endocrine disease, and hypertension. Her surgeries, serious illnesses, and accidents included an appendectomy, cholecystectomy, tonsillectomy, and adenoidectomy, and right ankle fracture.
PSYCHIATRIC HISTORY: Ms. Jones denied any history of inpatient psychiatric hospitalizations. She said she received began receiving outpatient psychiatric services many years ago, and is currently a patient at Psychological Services. Ms. Jones said she has been prescribed “Risperdal, Haldol, Geodon, Trazodone, and Seroquel” in the past, but was unsure what she is taking now. She indicated that without the medication, she hears “voices.” She stated that she is unable to discern what the voices are saying because they are “like in the distance.” She indicated that she has never been frightened of the voices or experienced any delusions or paranoia.
Ms. Jones also reported a history of mood disturbance. She said she has attempted to commit suicide on two occasions, once by cutting her wrists and once by attempting to overdose on her medications. She estimated those occurred in her 30’s and 40’s. Ms. Jones reported that she has also experienced symptoms consistent with mania, including a decreased need for sleep for three days, a significantly increased energy level, and increased goal-directed activity; specifically, shopping and spending all of her money on clothing and household items. She said that during those periods, she did not experience any grandiosity, racing thoughts, or rapid speech. Ms. Jones reported that those periods would cease when her friends would encourage her to resume taking her medications and go to see her counselor.
Records from General Hospital indicate on January 1, 2014, it was determined that Ms. Jones should be placed in a nursing home. She was diagnosed with schizoaffective disorder, cannabis abuse, and borderline personality disorder. It was noted that during periods of psychological decompensation, Ms. Jones becomes physically and verbally aggressive and moderately violent. She has also had auditory hallucinations. When informed that she would be going to a nursing home, Ms. Jones became verbally abusive, swung her walker at others, threatened to harm others, and threatened to harm herself. Indeed, she reportedly grabbed a phone cord and wrapped it around her neck. It was indicated that Ms. Jones had a lengthy history of psychiatric hospitalizations and had not been compliant with medications. Within the previous 30 days prior to that report, Ms. Jones’s symptoms included suicidal thoughts, suicidal threats, suicidal attempts, gestures, medication refusal, lability, hallucinations, anxiety, worry, panic reactions, verbal aggression, physical aggression, combative behaviors, destructive behaviors, threats toward others, abrasiveness, irritable behaviors, disruptive behaviors, conflicts with others, inappropriate communication of anger, self-injurious, self-abuse behaviors, need for restraints, refusal of care, resistance receiving care, inappropriate statements, inappropriate behaviors, and homicidal behaviors. It was reported that Ms. Jones required assistance with decision making, judgment, mobility, and ambulation.
In a similar assessment at General Hospital on January 1, 2015, it was again opined that Ms. Jones required nursing home placement. Her diagnosis at that time was bipolar disorder not otherwise specified and schizoaffective disorder.
PSYCHOLOGICAL TESTING: On the Independent Living Scales, Ms. Jones obtained a Full Scale score of 95, in the moderate range of functioning, consistent with individuals who live semi-independently. On the Memory/Orientation and Health and Safety subscales, her scores were in the high range, consistent with individuals who live independently. However, her scores on Managing Money, Managing Home and Transportation, and Social Adjustment were all in the moderate range. Her scores on Problem Solving were in the high range, but her scores on Performance/Information fell in the moderate range.
Specifically, on the Memory/Orientation items, Ms. Jones can remember her phone number and address and recall a list of items and the details of an appointment. She was well oriented to time and place. On the Health and Safety items, she was aware of how to call the police, get medical help, and handle her physical care and hygiene. She was also aware of how to take precautions to protect her safety. On the Managing Money items, Ms. Jones knew how she was supported financially, knew how to complete a money order, knew why it was important to pay bills, knew what health and home insurance are for, knew the purpose of a will, and knew why it was important to read documents carefully. On the other hand, she was unable to calculate how much change she should get back for a small purchase and was unable to perform basic math calculations. On the Managing Home and Transportation items, Ms. Jones knew how to use the phone, address an envelope, utilize public transportation, and figure out how to get home repairs done. However, she was unsure how to manage routine household problems or utilize a map. On the Social Adjustment items, Ms. Jones does not have any regular, in-person contact with anyone and was not sure she would be missed if she was no longer around. With regard to Problem Solving, Ms. Jones exhibits adequate ability to manage situations requiring reasoning ability. However, the Performance/Information items indicate she cannot perform many tasks independently and does not know the basic information for answering a question.
MENTAL STATUS EXAMINATION:
Appearance, Attitude, & Behavior: Ms. Jones is a 52-year-old Caucasian female of average height. She is overweight and used a wheelchair. She has short brown and grey hair. She was casually dressed and she had good hygiene. She made appropriate eye contact. She provided information in a clear and coherent manner, and she did not demonstrate any unusual physical movements. She needed glasses to read. Ms. Jones was cooperative and pleasant during this evaluation. She was friendly and offered personal information with ease. As the interview was conducted in her room, this examiner noted Ms. Jones kept her room neat and tidy.
Speech, Perception, Thought Process, & Thought Content: Ms. Jones’s speech was normal in tone and volume. Ms. Jones denied experiencing any current delusional beliefs, auditory or visual hallucinations, and there was no indication by her behavior or speech that she was experiencing any perceptual disturbances during this evaluation. Her thought process was logical and goal-directed.
Mood & Affect: Ms. Jones did not present with any observable symptoms of mania, including an abnormally elevated or irritable mood, grandiosity, increased talkativeness, or racing thoughts. In addition, Ms. Jones denied current suicidal and homicidal ideation. Her mood was euthymic and her affect was appropriate.
Cognition: Ms. Jones was oriented to person, place, and date. Her recent and remote memory were intact as demonstrated by her ability to recall recent and past personal information with ease. Ms. Jones displayed no difficulties with immediate recall, and could recall three of three words after a brief delay. Her attention and concentration were adequate, and she was able to spell world backwards and perform Serial 7 subtractions without error. Ms. Jones was able to sustain attention without difficulty throughout this interview.
Overall, results of the Folstein Mini-Mental State Exam indicated normal functioning (score 30 out of 30) in the areas of orientation, immediate recall, attention and calculation, recall, and language.
Insight & Judgment: Ms. Jones appeared to have good insight into her mental-health issues. When asked, “What do you do if you are the first person in a movie theater to see smoke and fire?” Ms. Jones replied, “Holler ‘Fire’ and get out,” and tell others to leave. When asked, “What would you do if you found on the street of a city an envelope that was sealed, addressed, and stamped?” she responded, “If it’s money, I’m keeping it,” but “maybe take it to the post office” otherwise. When asked, “Why shouldn’t people smoke in bed?” she replied, “Might catch fire.”
- Alcohol Use Disorder, Severe, In a Controlled Environment (303.90)
Ms. Jones has a problematic pattern of alcohol use. She reported that she developed tolerance to alcohol, experienced withdrawal symptoms when she could not drink, craved alcohol, gave up important activities to drink, had difficulty controlling her alcohol use, frequently drove a vehicle under the influence of alcohol, and continued to drink despite the legal and financial problems it caused her.
- Stimulant Use Disorder, Severe, In a Controlled Environment (304.20)
Ms. Jones also has a problematic pattern of crack cocaine use. She reported that she developed tolerance to cocaine, craved it, had difficulty controlling her use of that substance, spent a great deal of time involved in activities related to her cocaine use, gave up important activities to use cocaine, frequently drove a vehicle under the influence of cocaine, and continued to use it despite the financial problems it caused her.
- Unspecified Bipolar and Related Disorder (296.80)
Ms. Jones reported a history of manic episodes during which she experiences a decreased need for sleep, a significantly increased energy level, and increased goal-directed activity. At times, she has reportedly experienced auditory hallucinations as well. However, it is difficult to determine the extent to which her significant substance abuse and maladaptive personality traits contribute to her mood disturbance.
- Borderline Personality Traits
Ms. Jones also displays a pervasive pattern of instability in her interpersonal relationships and affects, as well as marked impulsivity. She has shown recurrent suicidal behavior, gestures, and threats.
- Opioid Use Disorder, Mild, In a Controlled Environment (305.50)
Ms. Jones reported that she abused her narcotic pain medication, Percocet. She said she gave up important activities to use opiates and frequently drove a vehicle under the influence of opiates.
- Cannabis Use Disorder, Mild, In a Controlled Environment (305.20)
Ms. Jones reported that she used marijuana daily for many years. She said she gave up important activities to use marijuana and frequently drove a vehicle under the influence of marijuana.
OPINION: According to all available information, Ms. Jones has adequate cognitive skills to reside semi-independently at this time (with significant assistance from case managers and other professional services). However, her psychological functioning is only at this adequate level currently because of the structure and supervision provided by the nursing home. Indeed, when last in an independent housing situation, Ms. Jones was heavily abusing alcohol and cocaine as well as marijuana and opiates. It does not appear that she has any significant periods of sobriety while living in the community. She was not always compliant with her psychotropic medication due to her substance use and other factors, which has resulted in psychological decompensation for her bipolar disorder. Ms. Jones also has a lengthy history of suicide attempts and aggression towards others. In addition, Ms. Jones has several serious medical conditions, including but not limited to: the inability to ambulate without a wheelchair, cancer, cirrhosis, and diabetes. Despite all of the aforementioned issues, Ms. Jones continues to believe that she could live independently in her own apartment, which is unrealistic. She does not have an adequate plan for maintaining sobriety and it is unlikely that she would be able to do so without her current level of support. Therefore, at this time, it is recommended that she continue to receive guardianship services.
Dr. Betty Rubble