Area 8 - Management of the Mental Illness

 

Due to mood swings, impulsivity, and difficulty managing emotional responses, member does not attend appointments with her psychiatrist or take medications that are prescribed to her. When she starts getting depressed, she withdraws further and further and attempts to self-treat her symptoms using illicit drugs and alcohol rather than reaching out for help.  "Eventually I wind up in the hospital," she says.

Due to memory deficits and disorganized thinking, member has recent history of missing appointments, not showing up for meetings with members of her treatment team, not taking her medications, and dropping out of treatment altogether.  Not taking meds was a major factor in her most recent hospitalization. Inability to manage her illness results in multiple functional impairments, most notably chronic homelessness and aggressiveness towards others.

Due to mood lability, impulsive behavior, and inability to regulate emotional responses, member has a long and recent history of inconsistent engagement with outpatient mental health providers and poor adherence to prescribed med regimens, resulting in hospitalizations, unemployment, inadequate income, inability to maintain stable housing, and homelessness.

Due to impulsivity, internalized anger, and hypersensitivity to feeling judged, member under-reports her symptoms and does not obtain consistent treatment for her mental illnesses. This has led to multiple hospitalizations, suicide attempts, and symptoms that are not well-controlled. Erratic participation in treatment has resulted in coping skills that are underdeveloped and underused, leading to ongoing outbursts of anger, conflicts with others, and excessive anxiety.

Due to feelings of hopelessness and irritability member has a documented recent history of stopping her medications on her own, without consulting or informing her doctor, if she feels they aren't working or aren't working fast enough.  Also, due to a lack of healthy coping skills, she engages in self-harm such as cutting and taking too much of her medications as a way of dealing with emotional pain. This results in hospitalization and puts her at risk of serious injury or death.
 
Due to social withdrawal, disorganized thinking and poor insight member does not engage with his treatment team on a consistent basis, doesn't show up for appointments and doesn't take his meds as prescribed, sometimes because he has run out of them and not bothered to refill them. Member also will not reach out to his treatment team for help until he is already in an extreme crisis and needs to be placed on a 5150 hold.  He was hospitalized for 2 weeks at the end of 2016.

Due to paranoia and persecutory delusions, member believes his treatment team has a secret agenda and that there is a conspiracy to harm or discredit him.  As a result he resists cooperative engagement and refuses to see his psychiatrist or take any medications.  He remains highly symptomatic and has not signed a treatment plan since 2014.  He will contribute to the plan, then change his mind at the last minute and refuse further involvement.

Due to A/H, paranoia, and disorganized thinking, and lack of self-awareness, member does not recognize that he has a mental illness and therefore makes only limited efforts at obtaining treatment and/or follow the recommendations of treatment providers he does see.  He does not take medications as prescribed and reports being confused about them and not knowing what they are. A/H makes it difficult for member to understand and retain things his providers tell him. He is therefore highly symptomatic and his behavior leads to social problems, unemployment, homelessness, & hospitalizations.

Due to A/H, paranoia, delusions, and disorganized thinking, member does not take oral medications consistently and will not come in for her injection (an injectable antipsychotic) which is the only thing that has ever worked for her. This is a problem because she if she is not medicated, she becomes extremely paranoid, delusional, and combative, to the extent that involuntary hospitalization is required.
  
Due to disorganized thinking and memory deficits, member only takes his medication some of the time. Other times he forgets about them, or can't remember why he is taking them, or pretends to take them but doesn't. He says they make him sleepy but doesn't appear to know why he actually stops. "I just know bad things happen when I don't take them," he says. "Then it's back to the hospital again. I don't like it there." Reports 3 hospitalizations in last 12 months.

Due to impulsivity and disorganized thinking, member has a history of missing appointments, not showing up for meetings with members of his treatment team, not taking his medications, and dropping out of treatment. Inability to manage his illness results in multiple functional impairments, most notably chronic homelessness and arguments with others that escalate to the point where police have to be called.

Due to mood swings, impulsivity, and difficulty managing her emotional responses, member does not attend appointments with her PSC or psychiatrist or take medications as prescribed on a consistent basis.  Symptoms of mental illness prevent her from working as noted in CFS 5 and cause severe impairment in terms of social/interpersonal skills, as she often escalates into shouting and threatening when there is conflict or disagreement.
 
Due to paranoia, lack of insight, and A/H, member does not believe he has a mental illness and has expressed a belief that others are trying to poison him. As a result, he will not take his meds or go to psych appointments unless continually prompted and in some cases pressured, according to his aunt.  Non-adherence with meds and resistance to treatment contributes to ongoing impairments in housing, social skills, and employment among others.
    
Due to paranoia, anxiety, and persecutory delusions, member gets into heated altercations with others which results in his being arrested, hospitalized, or admitted to acute care facilities. He was 5150'ed at Anaheim Global earlier this year and was admitted to the Treehouse twice, in July and Oct 2017. When discharged he did not continue taking medications or follow through with outpatient care as agreed, leading to repeated relapses and additional hospitalizations.

Member is strongly influenced by his culture and is ashamed of having a mental illness. Due to lack of insight and impulsivity (not thinking things through), when member’s symptoms subside, he convinces himself he is cured, or that he never had a mental illness to begin with, and then stops taking his meds. Due to suspiciousness he does not tell anyone what he is doing or seek anyone else's opinion, including his doctor's.  As his symptoms return he tries to hide them, and he can do this successfully for a while, but eventually the voices get so loud and the thoughts so bad that he needs to be hospitalized.
 
Due to paranoia, A/H, and delusional thinking, member has difficulty trusting psychiatrists and often expresses the belief that they are trying to harm or poison her. As a result, she has a history of being unwilling to follow their suggestions and take their advice. She will not attend appointments unless they are made for her and transportation is provided to and from.

Due to symptoms of mania (grandiose beliefs, impulsive behavior, and inappropriate elation), member becomes convinced she has been healed by God or that she no longer has an illness, leading her to abruptly stop taking her meds without informing her doctor. This is a recurring pattern that almost always leads to hospitalization. She was admitted to the hospital 4x in 2017 and has in excess of 100 lifetime hospitalizations per mother.

Due to shame, embarrassment, and cultural norms, member minimizes his symptoms even when they are severe and causing him a great deal of distress. As a result he can become extremely symptomatic without anyone knowing or attempting to intervene. He has been hospitalized between 15-20 times, 6-7 times in the last 5 years, with 4 suicide attempts. At least one S/A was a genuine attempt to end his life. Intense paranoia on the bus also interferes with his willingness to attend psych appointments.

Due to grandiose thinking, expansive mood, and lack of insight, member does not accept that he has a mental illness, so he continually misses appointments with his psychiatrist (he has still not completed his initial psych eval at TAO), avoids contact with his treatment team, tries to disenroll from services, and throws his meds away rather than taking them. As a result he remains prone to angry outbursts and impulsive behavior, leading to multiple impairments, ER visits, and 2 recent hospitalizations (2017 and 2018).
 
Member has a recurring pattern of getting stabilized on medication, then deciding he is cured or that he has the power to manage his symptoms without meds. At that point he stops taking his meds but does not tell anyone. If asked he will claim he is still taking them as prescribed.  Eventually he has another manic episode, spends through his money or gives it away, engages in offensive social behavior, begins having A/H & delusions, drops out of classes, has negative encounters with police, and gets hospitalized (last in 2016). When he gets discharged from the hospital the pattern repeats itself.

Member has a long history of stopping her medications or trying to change or adjust them in such a way that she experiences highs but not lows.  She will report taking her meds as prescribed, then later admit she was not.  During this assessment she said she had not been taking her meds as prescribed until about 10 days ago.  When member does not take her meds as prescribed, her voices get worse, she has command-type A/H, she gets manic and engages in high-risk behavior, or (most recently) very depressed with S/I and S/A's.
   
Due to grandiose delusions, member believes that he has a more accurate perception of his need for antipsychotic medications than his psychiatrist, and is therefore unwilling to consider changes to medications or dosages despite being highly symptomatic. When member is symptomatic, he is unable to remain focused or have a coherent conversation due to his responding to internal stimuli.

Due to lack of motivation and energy, anxiety, trouble concentrating, and impulsivity, member does not attend appointments with his psychiatrist and will not call and reschedule them when he misses them. He will not take his medications on his own or get them refilled.  His mother has to set up his appointments, provide transportation, and remind/prompt him multiple times to get him to take his meds and go to his appointments.  Even then, he will often still refuse to go and/or take his meds as prescribed.

Due to lack of motivation and energy, anxiety, trouble concentrating, and impulsivity, member does not attend appointments with his psychiatrist or call and reschedule missed appointments, and does not take his meds as prescribed. This leads to an increase in anxiety, fights with others, and thoughts of suicide which eventually become so frequent that hospitalization for DTS is required.

Due to impulsivity and trouble concentrating, member no-shows for most of his psychiatrist appointments, doesn’t take his meds as prescribed, and doesn’t follow doctors’ recommendations. In July 2017, for example, he was admitted to a hospital for S/I then changed his mind and left AMA. Inconsistent engagement results in member remaining highly symptomatic, leading to ongoing impairments in housing, employment, and others as noted on this page.

Due to disorganized thinking and avolition, member misses appointments with his psychiatrist, runs out of medications, and becomes disengaged from treatment altogether.  Medications do help reduce the severity of this symptoms, member acknowledges this, and when he is off them his impairments get significantly worse.  Despite this awareness, he will still disengage from treatment and stop taking his meds unless he is continually reminded and prompted by members of his team and/or his significant support persons.
 
Due to lack of motivation and energy and feelings of hopelessness, member withdraws from contact with treatment providers and supportive others when her depression gets worse. She stops taking her meds, stops seeing her PSC and doctors, and stops reaching out to others. She isolates in her room and stops eating. This leads to an escalation of symptoms that require emergency interventions up to and including acute care and hospitalization to resolve.
 
Due lack of motivation and energy, poor judgment, and trouble concentrating, member does not believe she has a mental illness and therefore does not meet with her treatment team on a consistent basis or take the medications that are prescribed to her. When she meets with her psychiatrist she will say she is taking her meds even when she is not, making assessment and treatment challenging for her doctor.  This is a problem because when she is off her meds, she experiences an exacerbation of symptoms which cause multiple impairments in various CFS areas such as her social functioning (See CFS 3) and employment (CFS 5).

Member will show up for appointments with his psychiatrist but due to irritability, impulsivity, and discomfort around others, if required to wait more than 2-3 min past his scheduled time he will get up and storm out. He demanded a transfer to TAO from another program because "no one did anything to help me there." His team believes his overreaction to minor inconveniences presents a significant barrier to recovery in that it leads to continual episodes of disengagement, running out of meds, and missed opportunities.
 
Due to impulsivity and disorganized thinking, member has a long and recent history of missing appointments, not showing up for meetings with members of his treatment team, not taking his medications, and dropping out of treatment altogether.  Inability to manage his illness results in multiple functional impairments, most notably chronic homelessness and conflicts with others (due to P/I), arrest/incarceration, and repeated hospitalizations (6 in the last 5 years).

Due impulsivity, trouble concentrating, lack of motivation, and feelings of hopelessness, member has a history of stopping her meds for 2-3 months at a time. In her words, "I get really hyper, manic, I start all this stuff, I try to do so many things at once and never finish any of them, I get paranoid, I get crazy."  Eventually she winds up in ERs, hospitals, or crisis residential centers to get her symptoms back under control.
  
Due to lack of motivation and energy, and on other occasions mania, member misses appointments with his psychiatrist and runs out of meds for 2-3 months at a time.  When he went to UCI with S/I recently he hadn't taken his meds in approximately 3 months. When depressed he doesn't have the energy "or the hope" to take his meds, and when he is manic he tries to selectively take his medications to sustain feelings of energy while avoiding depression. This doesn't work and he winds up being hospitalized with S/I.

Due to anosognosia and lack of insight, member is unaware of most of the symptoms of his mental illness and the impairments resulting from them. As a result he shows minimal interest in learning coping skills, misses most of his doctor's appointments, and only takes his meds occasionally.

Due to paranoia, delusional beliefs, and anxiety in social situations, member is reluctant to engage with members of her recovery team or meet with her psychiatrist on a regular basis. This is a problem because it interferes with Mary’s ability to get consistent mental health care, and results in her running out of medications. It has also prevented her from getting her injectable antipsychotic medication as scheduled, which has led to breakthrough symptoms (increased paranoia and delusional thoughts) between visits.

Due to mood swings, impulsivity, and difficulty managing her emotional responses, member does not attend appointments with her PSC or psychiatrist on a consistent basis. This makes it difficult to coordinate her care and ensure she has medications. Primary impairment in Area #8, however, appears to be a lack of effective coping skills, such as those associated with DBT, as medications alone do not provide a satisfactory reduction in symptoms.

Due to grandiose delusions, member believes that he has a more accurate perception of his need for antipsychotic medications than his psychiatrist, and is therefore unwilling to consider changes to medications or dosages despite being highly symptomatic. According to member, “It’s not my fault if other people aren’t intelligent enough to understand me.” Member is currently unable to remain focused or have a coherent conversation due to his responding to internal stimuli.

Member sees her psychiatrist on a regular basis and takes her medications as prescribed. However, due to symptoms of BPD and a lack of effective coping skills, member cuts herself as a way of dealing with intense emotions. During the last cycle, member made cuts to her thighs on 3 separate occasions, and on one occasion the cut was so deep that it required stitches to close. This method of dealing with emotional distress is a problem because in addition to disfiguring herself, member is putting herself at risk of severe injury or death if she inflicts more self-harm than she intends to, which could easily occur when she is intoxicated.

Due to diminished self-awareness, member has difficulty recognizing that she has a mental illness. She has some awareness of her symptoms, but underestimates their severity and does not believe they are the result of a mental disorder. For this reason, she is reluctant to allow her medications to be changed or dosages adjusted, despite being highly symptomatic.

Due to lack of motivation and energy, member sometimes misses appointments with her psychiatrist and doesn’t attend groups related to her recovery. According to Darlene, ”When I'm really depressed, I just don’t have the energy to come to those things. I stop doing everything, including taking my meds.” This is a problem because the more depressed Darlene becomes, the less likely she is to seek treatment. "It's a downward spiral," says Darlene, "that usually lands me in the hospital."

Due to feelings of hopelessness, member has difficulty imagining a better future for himself or describing any goals worth pursuing. As a result, his engagement is limited and he resists participating in the creation of his recovery plan. He misses most of his scheduled appointments with his doctor and will often decline to meet with members of his treatment team for several weeks at a time. “What’s the point?” asks the member. “Nothing’s ever going to change.”

Member was placed on conservatorship 6 months ago due to the severity of his symptoms and because he was unwilling to accept treatment voluntarily. Although meds reduce the severity of his symptoms, he has a history of disengaging from treatment, going off meds, and becoming highly symptomatic. When off meds he engages in self-mutilation, telling others he must cut himself "to pay for the sins of the world and make the demons go away".

Earlier in his life member was able to hold a job and support himself. After he became severely depressed, he began missing lots of work and was eventually fired. He then lost his apartment because he couldn’t pay the rent and had to sell his truck because he couldn’t afford to keep it registered and running.  With no place of his own and no way to get around, member says his life “fell apart.” He eventually got treatment for his depression but he still feels hopeless much of the time and his self-confidence is low. He reports feeling ashamed of himself. As a result he doesn’t take care of himself, put any effort into his appearance, look for work, or try to maintain friendships.

 

All PHI has been de-identified per HIPAA Privacy Rule