For Families Struggling with Mental Illness, Carolyn Wolf Is a Guide in the Darkness

When a life starts to unravel, where do you turn for help?

Melissa Klump began to slip in the eighth grade. She couldn’t focus in class, and in a moment of despair she swallowed 60 ibuprofen tablets. She was smart, pretty and ill: depression, attention deficit disorder, obsessive-compulsive disorder, either bipolar disorder or borderline personality disorder.

In her 20s, after a more serious suicide attempt, her parents sent her to a residential psychiatric treatment center, and from there to another. It was the treatment of last resort. When she was discharged from the second center last August after slapping another resident, her mother, Elisa Klump, was beside herself.

“I was banging my head against the wall,” the mother said. “What do I do next?” She frantically called support groups, therapy programs, suicide prevention lines, anybody, running down a list of names in a directory of mental health resources. “Finally,” she said, “somebody told me, ‘The person you need to talk to is Carolyn Wolf.’ ”

That call, she said, changed her life and her daughter’s. “Carolyn has given me hope,” she said. “I didn’t know there were people like her out there.”

Carolyn Reinach Wolf is not a psychiatrist or a mental health professional, but a lawyer who has carved out what she says is a unique niche, working with families like the Klumps.

One in 17 American adults suffers from a severe mental illness, and the systems into which they are plunged — hospitals, insurance companies, courts, social services — can be fragmented and overwhelming for families to manage. The recent shootings in Newtown, Conn., and Aurora, Colo., have brought attention to the need for intervention to prevent such extreme acts of violence, which are rare. But for the great majority of families watching their loved ones suffer, and often suffering themselves, the struggle can be boundless, with little guidance along the way.

“If you Google ‘mental health lawyer,’ ” said Ms. Wolf, a partner with Abrams & Fensterman, “I’m kinda the only game in town.”

On a recent afternoon, she described in her Midtown office the range of her practice.

“We have been known to pull people out of crack dens,” she said. “I have chased people around hotels all over the city with the N.Y.P.D. and my team to get them to a hospital. I had a case years ago where the person was on his way back from Europe, and the family was very concerned that he was symptomatic. I had security people meet him at J.F.K.”

Many lawyers work with mentally ill people or their families, but Ron Honberg, the national director of policy and legal affairs for the National Alliance on Mental Illness, said he did not know of another lawyer who did what Ms. Wolf does: providing families with a team of psychiatrists, social workers, case managers, life coaches, security guards and others, and then coordinating their services. It can be a lifeline — for people who can afford it, Mr. Honberg said. “Otherwise, families have to do this on their own,” he said. “It’s a 24-hour, 7-day-a-week job, and for some families it never ends.”

Many of Ms. Wolf’s clients declined to be interviewed for this article, but the few who spoke offered an unusual window on the arcane twists and turns of the mental health care system, even for families with money. Their stories illustrate how fraught and sometimes blind such a journey can be.

One rainy morning last month, Lance Sheena, 29, sat with his mother in the spacious family room of her Long Island home. Mr. Sheena was puffy-eyed and sporadically inattentive; the previous night, at the group home where he has been living since late last summer, another resident had been screaming incoherently and was taken away by the police. His mother, Susan Sheena, eased delicately into the family story.

“I don’t talk to a lot of people because they don’t get it,” Ms. Sheena said. “They mean well, but they don’t get it unless they’ve been through a similar experience. And anytime something comes up, like the shooting in Newtown, right away it goes to the mentally ill. And you think, maybe we shouldn’t be so public about this, because people are going to be afraid of us and Lance. It’s a big concern.”

Her son cut her off. “Are you comparing me to the guy that shot those people?”

“No, I’m saying that anytime there’s a shooting, like in Aurora, that’s when these things come out in the news.”

“Did you really just compare me to that guy?”

“No, I didn’t compare you.”

“Then what did you say?”

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Fee increases are making FHA mortgages more expensive

WASHINGTON — If you want to buy a house with minimal cash by using an FHA-insured mortgage, here's some sobering news: Because of an ongoing series of fee increases and underwriting tweaks, those mortgages are getting steadily more expensive and may not work for you.

The Federal Housing Administration is the largest source of low-down-payment mortgage money in the country. Its minimum down is just 3.5%, compared with 5% to 20% or more from conventional, non-government sources. For decades, FHA financing has made homeownership possible for first-time buyers with modest incomes and credit history blemishes.

But in the wake of losses tied to bad loans insured during the housing bust years, the FHA has been raising its loan insurance fees and backing more loans to applicants with higher credit scores. With the latest increases, things have gotten to the point where some lenders wonder whether the agency is trying to move away from its traditional customers.

Dennis C. Smith, broker and co-owner of Stratis Financial Corp. in Huntington Beach, is blunt: "I think FHA is putting itself out of business with the moves they've made in the past couple of years."

Although they wouldn't agree with that assessment, the FHA's top officials readily admit that their priority is not increasing market share but protecting the agency's multibillion-dollar insurance fund reserves and cutting losses.

Starting April 1, the FHA's annual mortgage insurance premiums for most new loans will jump one-tenth of a percentage point (10 basis points in lending parlance). This is on top of two previous increases since 2011.

Other changes that won't take effect until June 3 include mandatory manual underwriting of applications by borrowers whose total household debt-to-income ratios exceed 43% and who have credit scores below 620, and mandatory 5% minimum down payments on FHA loans above $625,500 in high-cost areas such as California, metropolitan Washington, D.C., and others.

The FHA also announced that as of June 3 it is rescinding its popular policy of canceling mortgage insurance premium charges for borrowers whose loan balances decline to 78% of the original amount. This will require FHA customers to pay premiums for as long as they keep their loans, and is in stark contrast to the private mortgage insurance market, in which homeowners can request cancellation of premium payments once their loans hit the 78% mark.

"That stinks," said Steve Stamets, a mortgage officer with Apex Home Loans in Rockville, Md. "It's just a money grab" that will cause creditworthy borrowers to avoid FHA loans and seek out low-down-payment alternatives through Fannie Mae and Freddie Mac, using private mortgage insurance.

Already, Stamets said, FHA is the more expensive option for many borrowers who have good credit but don't want to make hefty down payments.

He estimates that with the FHA's new fees, an applicant with a 720 FICO score making a 3.5% down payment on a $250,000, fixed-rate, 30-year FHA mortgage will pay $144.66 more a month than a borrower with the same credit score on a conventional loan of the same amount with a 5% down payment and private mortgage insurance.

Even with a 680 credit score, the conventional loan is cheaper by $85 a month based on the FHA's new fee levels, Stamets said. And those monthly premium payments can be canceled at the 78% loan-to-value level, whereas the FHA will keep charging them for the life of the mortgage.

Steven R. Maizes, managing director of mortgage banking for Mortgage Capital Partners Inc. in Los Angeles, says the FHA's new fees and policies are likely to cost the agency valuable low-risk business on refinancings. Maizes recently ran a spreadsheet analysis for a client with a $460,000 FHA loan at 5%. Even with a 1.5-point rate reduction, the added fees caused the monthly payment to decrease just $97.11.

"If you couple that [small saving] with the fact that the mortgage insurance payment can never go away," he said, refinancing an existing FHA loan for a creditworthy borrower into a new FHA loan will be tough to justify.

Bottom line for you: Make sure your loan officer runs the numbers comparing FHA loans with privately insured conventional alternatives. You may not want to be saddled indefinitely with higher payments — and no right to cancel.

kenharney@earthlink.net

Distributed by Washington Post Writers Group

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A delicate new balancing act in senior healthcare

When Claire Gordon arrived at Cedars-Sinai Medical Center, nurses knew she needed extra attention.

She was 96, had heart disease and a history of falls. Now she had pneumonia and the flu. A team of Cedars specialists converged on her case to ensure that a bad situation did not turn worse and that she didn't end up with a lengthy, costly hospital stay.

Frail seniors like Gordon account for a disproportionate share of healthcare expenditures because they are frequently hospitalized and often land in intensive care units or are readmitted soon after being released. Now the federal health reform law is driving sweeping changes in how hospitals treat a rapidly growing number of elderly patients.

The U.S. population is aging quickly: People older than 65 are expected to make up nearly 20% of it by 2030. Linda P. Fried, dean of the Columbia University Mailman School of Public Health, said now is the time to train professionals and test efforts to improve care and lower healthcare costs for elderly patients.

"It's incredibly important that we prepare for being in a society where there are a lot of older people," she said. "We have to do this type of experiment right now."

At Cedars-Sinai, where more than half the patients in the medical and surgical wards are 65 or older, one such effort is dubbed the "frailty project." Within 24 hours, nurses assess elderly patients for their risk of complications such as falls, bed sores and delirium. Then a nurse, social worker, pharmacist and physician assess the most vulnerable patients and make an action plan to help them.

The Cedars project stands out nationally because medical professionals are working together to identify high-risk patients at the front end of their hospitalizations to prevent problems at the back end, said Herb Schultz, regional director of the U.S. Department of Health and Human Services.

"For seniors, it is better care, it is high-quality care and it is peace of mind," he said.

The effort and others like it also have the potential to reduce healthcare costs by cutting preventable medical errors and readmissions, Schultz said. The federal law penalizes hospitals for both.

Gordon, an articulate woman with brightly painted fingernails and a sense of humor, arrived at Cedars-Sinai by ambulance on a Monday.

Soon, nurse Jacquelyn Maxton was at her bedside asking a series of questions to check for problems with sleep, diet and confusion. The answers led to Gordon's designation as a frail patient. The next day, the project team huddled down the hall and addressed her risks one by one. Medical staff would treat the flu and pneumonia while at the same time addressing underlying health issues that could extend Gordon's stay and slow her recovery, both in the hospital and after going home.

To reduce the chance of falls, nurses placed a yellow band on her wrist that read "fall risk" and ensured that she didn't get up on her own. To prevent bed sores, they got her up and moving as often as possible. To cut down on confusion, they reminded Gordon frequently where she was and made sure she got uninterrupted sleep. Medical staff also stopped a few unnecessary medications that Gordon had been prescribed before her admission, including a heavy narcotic and a sleeping pill.

"It is really a holistic approach to the patient, not just to the disease that they are in here for," said Glenn D. Braunstein, the hospital's vice president for clinical innovation.

Previously, nurse Ivy Dimalanta said, she and her colleagues provided similar care but on a much more random basis. Under the project, the care has become standardized.

The healthcare system has not been well designed to address the needs of seniors who may have had a lifetime of health problems, said Mary Naylor, gerontology professor at the University of Pennsylvania School of Nursing. As a result, patients sometimes fall through the cracks and return to hospitals again and again.

"That is not good for them and that is not good for society to be using resources in that way," Naylor said.

Using data from related projects, Cedars began a pilot program in 2011 and expanded it last summer. The research is continuing but early results suggest that the interventions are leading to fewer seniors being admitted to the intensive care unit and to shorter hospital stays, said Jeff Borenstein, researcher and lead clinician on the frailty project. "It definitely seems to be going in the right direction," he said.

The hospital is now working with Naylor and the University of Pennsylvania to design a program to help the patients once they go home.

"People who are frail are very vulnerable when they leave the hospital," said Harriet Udin Aronow, a researcher at Cedars. "We want to promote them being safe at home and continuing to recover."

In Gordon's case, she lives alone with the help of her children and a caregiver. The hospital didn't want her experiencing complications that would lengthen the stay, but they also didn't want to discharge her before she was ready. Under the health reform law, hospitals face penalties if patients come back too soon after being released.

Patients and their families often are unaware of the additional attention. Sitting in a chair in front of a vase of pink flowers, Gordon said she knew she would have to do her part to get out of the hospital quickly. "You have to move," she said. "I know you get bed sores if you stay in bed."

Gordon said she was comfortable at the hospital but she wanted to go back to her house as quickly as she could. "There's no place like home," she said.

Two days later, that's where she was.

anna.gorman@latimes.com

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Elton John shares Grammy stage with young rockers

LOS ANGELES (AP) — Elton John still fills stadiums worldwide on his own, but he'll share the spotlight with a dozen other musicians at Sunday's Grammy Awards.

The 65-year-old entertainer rehearsed Saturday at Staples Center alongside young Grammy nominees Mumford & Sons, Zac Brown, Ed Sheeran and Brittany Howard of Alabama Shakes.

John prepared for two performances: a rousing rendition of the Band's "The Weight" that also featured T. Bone Burnett and Mavis Staples, and a duet of Sheeran's single "The A Team."

"The fun of it for me is playing with other people," said John, wearing a navy Adidas tracksuit and his trademark red shades.

He also loves the Band's classic American sound.

"You've got a lot of British people up there playing American music, because that's what we love," he said of the Levon Helm tribute, which John dedicated to "the teachers and students of Sandy Hook Elementary School, whose songs ended too soon."

The Grammy Awards honor all kinds of music, but John said, "It should be more of a potpourri than it is."

"It's a bit ageist," he added.

"You're lucky it's ageist!" joked Grammy Awards executive producer Ken Ehrlich.

"T. Bone and I are the oldest people to play the Grammys," John said. "And we're only 30."

___

AP Entertainment Writer Sandy Cohen is on Twitter at http://www.twitter.com/APSandy .

___

Online:

http://www.grammy.com

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In Nigeria, Polio Vaccine Workers Are Killed by Gunmen

At least nine polio immunization workers were shot to death in northern Nigeria on Friday by gunmen who attacked two clinics, officials said.

The killings, with eerie echoes of attacks that killed nine female polio workers in Pakistan in December, represented another serious setback for the global effort to eradicate polio.

Most of the victims were women and were shot in the back of the head, local reports said.

A four-day vaccination drive had just ended in Kano State, where the killings took place, and the vaccinators were in a “mop-up” phase, looking for children who had been missed, said Sarah Crowe, a spokeswoman for the United Nations Children’s Fund, one of the agencies running the eradication campaign.

Dr. Mohammad Ali Pate, Nigeria’s minister of state for health, said in a telephone interview that it was not entirely clear whether the gunmen were specifically targeting polio workers or just attacking the health centers where vaccinators happened to be gathering early in the morning. “Health workers are soft targets,” he said.

No one immediately took responsibility, but suspicion fell on Boko Haram, a militant Islamist group that has attacked police stations, government offices and even a religious leader’s convoy.

Polio, which once paralyzed millions of children, is now down to fewer than 1,000 known cases around the world, and is endemic in only three countries: Nigeria, Pakistan and Afghanistan.

Since September — when a new polio operations center was opened in the capital and Nigeria’s president, Goodluck Jonathan, appointed a special adviser for polio — the country had been improving, said Dr. Bruce Aylward, chief of polio eradication for the World Health Organization. There have been no new cases since Dec. 3.

While vaccinators have not previously been killed in the country, there is a long history of Nigerian Muslims shunning the vaccine.

Ten years ago, immunization was suspended for 11 months as local governors waited for local scientists to investigate rumors that it caused AIDS or was a Western plot to sterilize Muslim girls. That hiatus let cases spread across Africa. The Nigerian strain of the virus even reached Saudi Arabia when a Nigerian child living in hills outside Mecca was paralyzed.

Heidi Larson, an anthropologist at the London School of Hygiene and Tropical Medicine who tracks vaccine issues, said the newest killings “are kind of mimicking what’s going on in Pakistan, and I feel it’s very much prompted by that.”

In a roundabout way, the C.I.A. has been blamed for the Pakistan killings. In its effort to track Osama bin Laden, the agency paid a Pakistani doctor to seek entry to Bin Laden’s compound on the pretext of vaccinating the children — presumably to get DNA samples as evidence that it was the right family. That enraged some Taliban factions in Pakistan, which outlawed vaccination in their areas and threatened vaccinators.

Nigerian police officials said the first shootings were of eight workers early in the morning at a clinic in the Tarauni neighborhood of Kano, the state capital; two or three died. A survivor said the two gunmen then set fire to a curtain, locked the doors and left.

“We summoned our courage and broke the door because we realized they wanted to burn us alive,” the survivor said from her bed at Aminu Kano Teaching Hospital.

About an hour later, six men on three-wheeled motorcycles stormed a clinic in the Haye neighborhood, a few miles away. They killed seven women waiting to collect vaccine.

Ten years ago, Dr. Larson said, she joined a door-to-door vaccination drive in northern Nigeria as a Unicef communications officer, “and even then we were trying to calm rumors that the C.I.A. was involved,” she said. The Iraq and Afghanistan wars had convinced poor Muslims in many countries that Americans hated them, and some believed the American-made vaccine was a plot by Western drug companies and intelligence agencies.

Since the vaccine ruse in Pakistan, she said, “Frankly, now, I can’t go to them and say, ‘The C.I.A. isn’t involved.’ ”

Dr. Pate said the attack would not stop the newly reinvigorated eradication drive, adding, “This isn’t going to deter us from getting everyone vaccinated to save the lives of our children.”

Aminu Abubakar contributed reported from Kano, Nigeria.

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Entrepreneur Brian Lee is business partner to the stars

The gig: Lawyer-turned-serial-entrepreneur Brian Lee, 41, is pulling double duty as the chief executive of two celebrity-backed e-commerce websites: ShoeDazzle, co-founded with Kim Kardashian, and Honest Co., co-founded with Jessica Alba. The companies are headquartered in Santa Monica and offer customers monthly subscription plans in addition to typical a la carte shopping for shoes and baby products, respectively.

ShoeDazzle has more than 15 million registered users and last year posted $100 million in revenue, up 80% from 2011; it has raised $66 million from investors including venture capital firm Andreessen Horowitz. Honest Co., launched a year ago, has yet to release membership or financial numbers but has raised $27 million.

From Seoul to L.A.: Lee was born in Seoul. When he was 1, his family immigrated to Huntington Beach, where he grew up.

As an 8-year-old, Lee mapped out his trick-or-treating route on Halloween so he could collect as much candy as possible. When he got home, he separated his loot into Ziploc bags, which he sold at school for 25 cents each.

"Cost of goods: zero. Profit margins: 100%, outside of my own little labor," he said. "I probably did that for five years."

He now lives in Marina del Rey with his wife, Mira; their 4-year-old son, Davis; and their 1-year-old daughter, Madison.

Education: Bachelor's degree in business economics from UCLA in 1993, J.D. from UCLA School of Law in 1996.

Bold cold call: After practicing law for a few years, Lee came up with the idea for LegalZoom, which offers self-help legal documents such as divorce and bankruptcy forms, prenuptial agreements and wills. He wanted a high-profile name to represent the start-up, and decided to approach O.J. Simpson defense attorney Robert Shapiro.

Lee got Shapiro's number from 411 and called him at 10 p.m. "He picked up the phone and said, 'Hi, this is Robert Shapiro, how can I help you?' and I said, 'Well, my name is Brian Lee and I have a business opportunity I'd like to run by you.'... I think he heard the desperation in my voice and he said, 'You've got two minutes.'"

LegalZoom, based in Glendale, launched in 2001.

Online shoe shopping: ShoeDazzle was inspired by Lee's wife, who one day returned from a shopping spree on Robertson Boulevard with a pair of pricey designer shoes. When Lee asked her why she didn't just go to Loehmann's or DSW, she said discount chains didn't provide the type of personalized, one-on-one service that small boutiques did. Lee set out to replicate that experience online and met Kardashian through Shapiro, who is a family friend.

ShoeDazzle launched four years ago as an online subscription business, with members viewing a customized showroom of shoes based on a personal fashion quiz and choosing one new pair to receive every month for $39.95 including shipping.

Taking back the reins: In November, Lee became CEO of ShoeDazzle for a second time. He returned after the departure of Bill Strauss, who scrapped the company's subscription-based business model last year, leading to speculation that the company wasn't doing well.

In his first 100 days on the job, Lee laid off about two dozen employees and hired celebrity fashion stylist Rachel Zoe as the company's chief stylist; ShoeDazzle also began introducing one new shoe style every day. This month the company will roll out an optional $9.95-a-month VIP membership program that includes free shipping, early access to sales, discounts and an extended return policy.

Since a site relaunch in January, orders have increased 30% and repeat visits are up 12%, Lee said. The company sells as many as 250,000 pairs of shoes per month.

From shoes to babies: Lee was approached by Alba when the actress wanted to start an eco-friendly baby products line. Honest Co. sells diapers, shampoo, sunscreen and household items online that are nontoxic and made with organic ingredients.

Caffeine junkie: As the CEO of two companies, Lee arrives at Honest Co. offices by 7 a.m. every day and is there until 9:30 a.m. He then heads over to nearby ShoeDazzle, where he stays until 5 p.m. or so. Then it's back to Honest Co. until about 8 or 9 p.m.

"I drink seven Coca-Colas a day," he said. "Regular Coke, which is really bad for me."

Advice to entrepreneurs: "Believe in the idea with 100% certainty," Lee said. "But also don't be scared to change that idea and pivot very quickly. Because as an entrepreneur, nothing ever goes to plan."

For instance, Lee said that in the early days of LegalZoom, the company created do-it-yourself software programs such as Estate Planning in a Box that it hoped to sell at Staples and OfficeMax. When LegalZoom realized that Internet-based downloading was the future, it dropped those plans.

"We spent a lot of resources on it," he said, "but we weren't afraid at all to just cut it."

andrea.chang@latimes.com

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Big Bear locked down amid manhunt

The bustling winter resort of Big Bear took on the appearance of a ghost town Thursday as surveillance aircraft buzzed overhead and police in tactical gear and carrying rifles patrolled mountain roads in convoys of SUVs, while others stood guard along major intersections.

Even before authorities had confirmed that the torched pickup truck discovered on a quiet forest road belonged to suspected gunman Christopher Dorner, 33, officials had ordered an emergency lockdown of local businesses, homes and the town's popular ski resorts. Parents were told to pick up their children from school, as rolling yellow buses might pose a target to an unpredictable fugitive on the run.

By nightfall, many residents had barricaded their doors as they prepared for a long, anxious evening.

PHOTOS: A tense manhunt amid tragic deaths

"We're all just stressed," said Andrea Burtons as she stocked up on provisions at a convenience store. "I have to go pick up my brother and get him home where we're safe."

Police ordered the lockdown about 9:30 a.m. as authorities throughout Southern California launched an immense manhunt for the former lawman, who is accused of killing three people as part of a long-standing grudge against the LAPD. Dorner is believed to have penned a long, angry manifesto on Facebook saying that he was unfairly fired from the force and was now seeking vengeance.

Forest lands surrounding Big Bear Lake are cross-hatched with fire roads and trails leading in all directions, and the snow-capped mountains can provide both cover and extreme challenges to a fugitive on foot. It was unclear whether Dorner was prepared for such rugged terrain.

Footprints were found leading from Dorner's burned pickup truck into the snow off Forest Road 2N10 and Club View Drive in Big Bear Lake.

San Bernardino County Sheriff John McMahon said that although authorities had deployed 125 officers for tracking and door-to-door searches, officers had to be mindful that the suspect may have set a trap.

"Certainly. There's always that concern and we're extremely careful and we're worried about this individual," McMahon said. "We're taking every precaution we can."

PHOTOS: A fugitive's life on Facebook

Big Bear has roughly 400 homes, but authorities guessed that only 40% are occupied year-round.

The search will probably play out with the backdrop of a winter storm that is expected to hit the area after midnight.

Up to 6 inches of snow could blanket local mountains, the National Weather Service said.

FULL COVERAGE: Sweeping manhunt for rampaging ex-cop

Gusts up to 50 mph could hit the region, said National Weather Service meteorologist Mark Moede, creating a wind-chill factor of 15 to 20 degrees.

Extra patrols were brought in to check vehicles coming and going from Big Bear, McMahon said, but no vehicles had been reported stolen.

"He could be anywhere at this point," McMahon said. When asked if the burned truck was a possible diversion, McMahon replied: "Anything's possible."

Dorner had no known connection to the area, authorities said.

Craig and Christine Winnegar, of Murrieta, found themselves caught up in the lockdown by accident. Craig brought his wife to Big Bear as a surprise to celebrate their 28th wedding anniversary. Their prearranged dinner was canceled when restaurant owners closed their doors out of fear.

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Tyler, Fleetwood push Hawaii celeb privacy bill

HONOLULU (AP) — Rock legends Steven Tyler and Mick Fleetwood have convinced a Hawaii Senate committee to approve a bill to protect celebrities or anyone else from intrusive paparazzi.

The state Senate Judiciary Committee approved the so-called Steven Tyler Act Friday after the stars testified at a hearing.

The bill would give people power to sue others who take photos or video of their private lives in an offensive way.

Tyler says he asked state Sen. Kalani English to introduce the measure after paparazzi took a photo of the Aerosmith frontman and his girlfriend in his home, causing a ripple in his family.

The former "American Idol" judge says his kids don't want to go out with him in Hawaii because of the threat of paparazzi.

Opponents say the bill limits constitutional rights.

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Well: Think Like a Doctor: A Confused and Terrified Patient

The Challenge: Can you solve the mystery of a middle-aged man recovering from a serious illness who suddenly becomes frightened and confused?

Every month the Diagnosis column of The New York Times Magazine asks Well readers to sift through a difficult case and solve a diagnostic riddle. Below you will find a summary of a case involving a 55-year-old man well on his way to recovering from a series of illnesses when he suddenly becomes confused and paranoid. I will provide you with the main medical notes, labs and imaging results available to the doctor who made the diagnosis.

The first reader to figure out this case will get a signed copy of my book, “Every Patient Tells a Story,” along with the satisfaction of knowing you solved a case of Sherlockian complexity. Good luck.

The Presenting Problem:

A 55-year-old man who is recovering from a devastating injury in a rehabilitation facility suddenly becomes confused, frightened and paranoid.

The Patient’s Story:

The patient, who was recovering from a terrible injury and was too weak to walk, had been found on the floor of his room at the extended care facility, raving that there were people out to get him. He was taken to the emergency room at the Waterbury Hospital in Connecticut, where he was diagnosed with a urinary tract infection and admitted to the hospital for treatment. Doctors thought his delirium was caused by the infection, but after 24 hours, despite receiving the appropriate antibiotics, the patient remained disoriented and frightened.

A Sister’s Visit:

The man’s sister came to visit him on his second day in the hospital. As she walked into the room she was immediately struck by her brother’s distress.

“Get me out of here!” the man shouted from his hospital bed. “They are coming to get me. I gotta get out of here!”

His brown eyes darted from side to side as if searching for his would-be attackers. His arms and legs shook with fear. He looked terrified.

For the past few months, the man had been in and out of the hospital, but he had been getting better — at least he had been improving the last time his sister saw him, the week before. She hurried into the bustling hallway and found a nurse. “What the hell is going on with my brother?” she demanded.

A Long Series of Illnesses:

Three months earlier, the patient had been admitted to that same hospital with delirium tremens. After years of alcohol abuse, he had suddenly stopped drinking a couple of days before, and his body was wracked by the sudden loss of the chemical he had become addicted to. He’d spent an entire week in the hospital but finally recovered. He was sent home, but he didn’t stay there for long.

The following week, when his sister hadn’t heard from him for a couple of days, she forced her way into his home. There she found him, unconscious, in the basement, at the bottom of his staircase. He had fallen, and it looked as if he may have been there for two, possibly three, days. He was close to death. Indeed, in the ambulance on the way to the hospital, his heart had stopped. Rapid action by the E.M.T.’s brought his heart back to life, and he made it to the hospital.

There the extent of the damage became clear. The man’s kidneys had stopped working, and his body chemistry was completely out of whack. He had a severe concussion. And he’d had a heart attack.

He remained in the intensive care unit for nearly three weeks, and in the hospital another two weeks. Even after these weeks of care and recovery, the toll of his injury was terrible. His kidneys were not working, so he required dialysis three times a week. He had needed a machine to help him breathe for so long that he now had to get oxygen through a hole that had been cut into his throat. His arms and legs were so weak that he could not even lift them, and because he was unable even to swallow, he had to be fed through a tube that went directly into his stomach.

Finally, after five weeks in the hospital, he was well enough to be moved to a short-term rehabilitation hospital to complete the long road to recovery. But he was still far from healthy. The laughing, swaggering, Harley-riding man his sister had known until that terrible fall seemed a distant memory, though she saw that he was slowly getting better. He had even started to smile and make jokes. He was confident, he had told her, that with a lot of hard work he could get back to normal. So was she; she knew he was tough.

Back to the Hospital:

The patient had been at the rehab facility for just over two weeks when the staff noticed a sudden change in him. He had stopped smiling and was no longer making jokes. Instead, he talked about people that no one else could see. And he was worried that they wanted to harm him. When he remained confused for a second day, they sent him to the emergency room.

You can see the records from that E.R. visit here.

The man told the E.R. doctor that he knew he was having hallucinations. He thought they had started when he had begun taking a pill to help him sleep a couple of days earlier. It seemed a reasonable explanation, since the medication was known to cause delirium in some people. The hospital psychiatrist took him off that medication and sent him back to rehab that evening with a different sleeping pill.

Back to the Hospital, Again:

Two days later, the patient was back in the emergency room. He was still seeing things that weren’t there, but now he was quite confused as well. He knew his name but couldn’t remember what day or month it was, or even what year. And he had no idea where he was, or where he had just come from.

When the medical team saw the patient after he had been admitted, he was unable to provide any useful medical history. His medical records outlined his earlier hospitalizations, and records from the nursing home filled in additional details. The patient had a history of high blood pressure, depression and alcoholism. He was on a long list of medications. And he had been confused for the past several days.

On examination, he had no fever, although a couple of hours earlier his temperature had been 100.0 degrees. His heart was racing, and his blood pressure was sky high. His arms and legs were weak and swollen. His legs were shaking, and his reflexes were very brisk. Indeed, when his ankle was flexed suddenly, it continued to jerk back and forth on its own three or four times before stopping, a phenomenon known as clonus.

His labs were unchanged from the previous visit except for his urine, which showed signs of a serious infection. A CT scan of the brain was unremarkable, as was a chest X-ray. He was started on an intravenous antibiotic to treat the infection. The thinking was that perhaps the infection was causing the patient’s confusion.

You can see the notes from that second hospital visit here.

His sister had come to visit him the next day, when he was as confused as he had ever been. He was now trembling all over and looked scared to death, terrified. He was certain he was being pursued.

That is when she confronted the nurse, demanding to know what was going on with her brother. The nurse didn’t know. No one did. His urinary tract infection was being treated with antibiotics, but he continued to have a rapid heart rate and elevated blood pressure, along with terrifying hallucinations.

Solving the Mystery:

Can you figure out why this man was so confused and tremulous? I have provided you with all the data available to the doctor who made the diagnosis. The case is not easy — that is why it is here. I’ll post the answer on Friday.

Friday Feb. 8 4:13 p.m. | Updated Thanks for all your responses. You can read about the winner at “Think Like a Doctor: A Confused and Terrified Patient Solved.”

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Rules and Regulations: Post your questions and diagnosis in the comments section below.. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

Correction: The patient’s eyes were brown, not blue.

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Stocks close higher; S&P 500 highest since Nov. `07

The Standard and Poor's 500 edged up to a five-year high Friday, extending a rally that started in January.

The S&P 500 rose 8.54 points to 1,517.93, closing 0.3 percent up for the week. The index is at its highest since November 2007 and has advanced for six weeks, the longest streak of gains since August.

The Dow Jones industrial average rose 48.92 points, or 0.4 percent, to 13,992.97. The Nasdaq composite climbed 28.74 points, or 0.9 percent, to finish the week at 3,193.87.

The Dow had its best January in almost two decades, and closed above 14,000 on Feb. 1 for the first time since 2007. The index is up 6.8 percent so far this year; the S&P 500 is up 6.4 percent.

A last-minute budget deal in Washington to avoid the “fiscal cliff” of tax hikes and spending cuts helped powered the rally, as did as optimism about the housing sector and gradual improvements in the jobs market.

The S&P 500 finished the week higher despite logging its biggest daily decline in almost three months Monday following worrying news from Europe.

The index fell 1.2 percent that day as bond yields in Spain and Italy rose on concern that the region's politicians will drag Europe back into crisis. European Central Bank President Mario Draghi's cautious comments about the region's economy also weighed on markets Thursday.

“Everybody seems to be saying this market needs to correct,” said Robert Pavlik, chief market strategist at Banyan Partners. “Nobody wants to be in it, but nobody wants to be out of it.”

Largely positive corporate earnings reports and a report that showed that the U.S. trade deficit narrowed sharply in December provided more fuel for the market's advance Friday.

The trade deficit fell nearly 21 percent in December from November to $38.6 billion, the smallest in nearly three years, as exports rose while oil imports plummeted. The smaller trade gap means the economy likely performed better in the final three months of last year than first reported last week.

“The trade balance was surprisingly very good,” said Phil Orlando, chief market strategist at Federated Investors.

The government estimated that the U.S. economy contracted at an annual rate of 0.1 percent in the last three months of 2012. Orlando estimates that may now be revised to growth of 0.5 percent.

Shares of LinkedIn, the online professional networking service, jumped $26.39, or 21.3 percent, to $150.40 after the company reported fourth-quarter results late Thursday that beat analysts' forecasts. AOL soared $2.31 to $33.72 after the Internet company said its quarterly revenue grew for the first time in eight years, helped by strength in worldwide advertising.

Currently, analysts are expecting earnings for the fourth quarter of 2012 to rise 6.5 percent for S&P 500 companies, according to data from S&P Capital I&Q. That's an increase from the 2.4 percent growth rate recorded for the preceding quarter.

Stocks have benefited as investors poured a net $4.1 billion into stock mutual funds since the start of the year, according to data provided by Lipper.

“I'm very encouraged by the fact, that finally, for the first time in many years, individual investors seem to be participating in this,” said David Kelly, chief global strategist at J.P. Morgan Funds.

The yield on the 10-year note, which moves inversely to its price, fell one basis point to 1.95 percent.

Trading volume was light as Wall Street braced for what is forecast to be the largest winter storm in more than a year. Up to 2 feet of snow forecast along the densely populated Interstate 95 corridor from the New York City area to Boston and beyond.

Among other stocks making big moves;

— Microchip Technology, a semiconductor maker, jumped $2.45, or 7.2 percent, to $36.39 after its earnings beat estimates. The company said it was seeing “exceptionally strong” bookings.

— Moody's slumped $3.62, or 7.7 percent, to $43.37 even after reporting that fourth-quarter net income jumped 66 percent and revenue blew away expectations. Many are expecting the ratings agency will be the next target of the Justice Department, which filed a suit against rival Standard & Poor's for its actions before the housing market collapse.

— Activision Blizzard, which makes “Call of Duty” and other video games, rose $1.35, or 11.2 percent, to $13.41. The company posted sharply higher earnings and revenue in the fourth quarter, surpassing Wall Street's expectations.

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