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United States v. Armstrong

July 29, 2008


The opinion of the court was delivered by: McLAUGHLIN, Sean J., District J.,


Defendant, Marjorie Diehl-Armstrong, is charged in this case with one count each of conspiracy to commit armed bank robbery, bank robbery, and carrying and using a firearm during and in relation to a crime of violence. On January 24, 2008, Defense Counsel filed a motion for a hearing to determine the Defendant's competency, noting that Dr. Robert L. Sadoff had examined the Defendant and concluded within reasonable medical certainty that the Defendant is not competent to stand trial on the charges against her. Pursuant to 18 U.S.C. § 4141(b) and 4247(b) and (c), this Court ordered that the Defendant be committed to the custody of the Attorney General for further psychological or psychiatric testing.

Defendant was designated to the Metropolitan Correctional Center of New York, where she was examined by William J. Ryan, Ph.D., a licensed psychologist employed by the Federal Bureau of Prisons. On April 15, 2008, Dr. Ryan completed his report, concluding that the Defendant is competent to stand trial.

This Court held a two-day hearing from May 21-22, 2008, during which time it heard testimony from several expert and lay witnesses and received voluminous medical records. The parties have since submitted their respective proposed findings of fact and conclusions of law and the matter is now ripe for adjudication.


Defendant's Early Medical History

Defendant is a 59-year old female currently serving a prison term for third-degree murder in a separate criminal matter. She holds a master's degree in counseling and is considered to be very intelligent.

The evidentiary record, which is quite extensive, reveals that Defendant has had a long history of mental health issues dating back to at least her early adulthood. She has reported to evaluators that she suffered from anorexia nervosa during her adolescent years. (See Ex. 2, p. 4; Ex. 17, p. 1; Ex. A-920.)

From December of 1973 through June of 1974 she received treatment through Hamot Community Mental Health Services. Her presenting problems included "nervousness, tension and anxiety, and an expressed inability to have close gratifying relationships." (Ex. 12.) The focus of her treatment was individual therapy, but it was perceived that she was defensive and showed little commitment to making any changes and, therefore, her improvement was considered doubtful. Her final diagnosis was passive-aggressive personality with hysterical features. (Id.)

Between May 5, 1976 and July 29, 1977 she was seen 38 times by Robert B. Callahan, M.D.. (Ex. A-845.) At the time of her initial evaluation, she was felt to have multiple depressive symptoms and to be incapable of holding employment. (Id.) Dr. Callahan treated Defendant with individual psychotherapy and Tofranil, which he felt produced moderate success. (Id.) His final diagnosis was Manic Depressive Disorder -- depressed type*fn2 and Cyclothymic Disorder. (Ex. A-849.)

Treatment notes from 1981 indicate that Defendant was referred to St. Vincent Health Center for complaints of depression. (Ex. A-896.) She was seen on August 6, 1981 and the clinical impression at that time was Cyclothymic Disorder*fn3 and Manic Episode. (Id.) She was seen again on December 15, 1981, at which time her presenting problems were depression, difficulty in interpersonal relationships, and severely impaired social and occupational functioning. (Ex. 14; Ex. A-900.) Clinical impressions at that time were "Persistent depression -- possible hypomanic episodes" as well as "Mixed Personality Disorder (rigid, manipulative, angry, deceitful)." (Id.)

The evidence shows that the Defendant made attempts in the early 1980's to secure Social Security Disability Insurance benefits based upon her mental health problems. On December 15, 1981 the Defendant sent a letter to her treating psychiatrist, Paul Francis, M.D., which states, in relevant part:

Please fill out the enclosed form and return it to me as soon as possible. ...

I submitted the letter documenting the severe TMJ (myofacial [sic] pain syndrome) problem, but was notified this was not enough. Bureaucratic requirements need to mention "permanent disability."

Obviously, they ignored the dentist's use of "permanent disability." I have spent a lot of time and money over the last year or so trying to get the small amount which I feel I deserve. I am really frustrated. After all I can't even get a small rebate much less any disability from social security. ... Being on welfare is degrading and doesn't really reflect my problems. Will you help me by documenting as best you can that I have a "permanent disability" psychologically? ...

I am having a lot of anxiety. My financial situation would be improved if I was to receive this little compensation, I would be much better off psychologically. ...

Please help me. I can't afford a lawyer for this. This wouldn't cause me to "give up." You are the only one to whom I can turn....

(Ex. 6.)

Thereafter, on December 22, 1981 Dr. Francis completed a form stating that Defendant had "Persistent depression and associated symptoms for over 10 years. Long standing difficulties with interpersonal relationships and severe impairments in social and occupational functioning. Personality style manifested by rigidity and hostility." (Ex. 13.) Dr. Francis diagnosed Dysthymic Disorder*fn4 and Mixed Personality Disorder and assigned Defendant a poor prognosis because of the "chronicity" of Defendant's problems and the fact that previous therapy had produced no sustained benefit for her. (Id.)

On June 2, 1982, a client advocate at St. Vincent reported that Defendant had registered a complaint based on Dr. Francis' unwillingness to provide a more detailed report to the Social Security Administration in support of Defendant's SSI claim. (Ex. 4.) According to this report, Dr. Francis had refused the request because the Defendant had not been seen since November of 1981 and a re-evaluation would therefore be necessary to re-evaluate the Defendant's current mental health condition. However, Dr. Francis was unwilling to schedule another appointment with the Defendant due to her history of missed appointments and failure to comply with treatment recommendations. (Id.) The report reflects that other options were discussed with the Defendant, including evaluation by another psychiatrist at St. Vincent. (Id.)

Defendant ultimately agreed to be seen by Dr. Pandya*fn5 at St. Vincent Community Mental Health Center and was evaluated on August 25, 1982. At that time she complained of, among other things, over-eating, over-sleeping, gaining weight, having crying spells, and experiencing feelings of procrastination over the course of the prior month. Prior to that point she had reportedly been in a "manic" state and had had great energy. Dr. Pandya diagnosed the Defendant with Manic Depressive Disorder -- depressed type, and cyclothymic personality. (Ex. A-919-920.)

Defendant's efforts to obtain Social Security Disability Insurance benefits continued into 1983, as documented by correspondence from Northwestern Legal Services and various outpatient treatment forms from St. Vincent Community Mental Health Center. Collectively, these documents evidence the Defendant's continued attempts to obtain, and her anger over being denied, social security and welfare benefits. (Ex. 5, 7-10.)

A St. Vincent form entitled "Summary of Appeal to Client Advocate" and dated May 17-20, 1983, is illustrative. (Ex. 11.) That document indicates that the Defendant had been referred to the client advocate based on complaints that her then-treating psychiatrist, Dr. Choksi, had failed to fill out a disability evaluation form in a manner that would qualify her for disability and public housing. (Id.) It was noted that the Defendant had lodged similar complaints against Dr. Francis and, as a result, had been transferred to Dr. Pandya and, later, to Dr. Choksi. (Id.) The Summary of Appeal form indicates that, while Dr. Choksi believed Defendant to have severe psychiatric problems, he could not go further in his assessment because of insufficient time with the Defendant and because it was "difficult to assess the actual extent of the disability" considering the fact that "all her verbalizations in [appointments] are geared toward 'proving' her disability." (Id.) The document suggests that the Defendant had been offered in-patient services in order to provide for a more extensive evaluation; however, she declined this option. Defendant had also declined to obtain a private evaluation. She was reluctant to return to either Dr. Pandya or Dr. Choksi, and Dr. Francis had refused to accept her back as a patient; therefore, it was perceived that the Defendant had very few options left. (Id.) According to the Summary of Appeal form, the client advocate advised the Defendant to continue treatment with Dr. Pandya, but it was "[e]mphasized that this in no way implied that we would make a more extreme report to SSI." (Id.) Ultimately, the Defendant agreed to a tentative appointment with Dr. Pandya, but it was noted that, throughout her contacts with the client advocate, the Defendant had been at times hostile and abusive, and the final contact had ended with the Defendant engaging in much verbal abuse and hanging up. (Id.)

On March 30, 1984, the Defendant was seen once more by Dr. Francis. Treatment notes indicate that Dr. Francis felt her problem was "primarily characterological" and his treatment recommendation, as in the past, was for the Defendant to receive outpatient therapy. The notes further indicate that the Defendant was "seen by assessment today to offer evaluation [and] referral by them; reportedly she became angry [and] left. Wanted the doctor to sign some papers." (Ex. 15.)

The Robert Thomas Homicide

On August 1, 1984, Defendant was arrested on charges of homicide in the killing of her then-boyfriend, Robert Thomas. Upon her arrest, she was lodged at the Erie County Prison. When law enforcement officers searched the Defendant's home, they uncovered a bizarre inventory of food stuffs including, among other things, almost 400 pounds of butter and over 700 pounds of cheese, much of which was unrefrigerated and rotting. (Ex. B.)

In January of 1985, her parents retained Leonard G. Ambrose, III, Esq., to represent her in connection with the Thomas homicide. Due to his concerns about the Defendant's mental state, Mr. Ambrose had the Defendant examined by Robert Sadoff, M.D. on two occasions during April of 1985. In addition, Dr. Sadoff referred the Defendant to Gerald Cooke, Ph.D., for psychological testing.

In a report dated June 7, 1985, Dr. Sadoff recounted that he had examined the Defendant on April 25 and April 29, 1985 for three hours and over one hour, respectively. He found that, during his examination, she was "clearly hypomanic" and "rambled with a flight of ideas typical of the manic patient." (Ex. A-861.) She could not stay focused on any particular subject for long and would refer to unrequested, extraneous material. (Id.) According to Dr. Sadoff, "[h]er response to a question may have taken one half to one hour when a simple response would have sufficed." (Id.) A mental status examination revealed that the Defendant had occasional sensory distortion and difficulty with perception. She would refer to voices and multiple thoughts that come at her simultaneously. (Id.) On the other hand, the Defendant's examination also revealed that she was very bright, had good memory and recall, could abstract proverbs, and could subtract serial numbers without difficulty. (Ex. A-862.) With regard to her competency, Dr. Sadoff found the following:

When she becomes excessively hypomanic, as she has in my presence, she is not competent to communicate effectively. Although she appears very bright and appears to have good memory, she is currently suffering from a psychotic illness called bipolar disorder or manic depressive psychosis. This illness has rendered Marjorie Diehl incompetent to stand trial at the present time because of her inability to communicate effectively with counsel and her inability, because of the rapid thoughts that bombard her at once during her manic phase, to appreciate her position within this legal situation.

(Id.) Dr. Sadoff felt that the Defendant should be tried on Lithium and that, without such medication, it was unlikely that she would become competent to proceed legally in the foreseeable future. (Id.)

Defendant was re-examined by Dr. Sadoff on February 19, 1986. (Ex. A-867.) At the time of this examination, the Defendant's course of Lithium had reached the therapeutic range. (Id.) Dr. Sadoff reported that, while her manic episodes had decreased, she continued to evidence manic behavior and rapid thought processes. (Id.) She still evidenced fairly rapid and pressured speech along with flight of ideas and, when asked open-ended questions, she would offer non-responsive, free associations. Moreover, the Defendant was now showing what Dr. Sadoff termed "a clear paranoid ideation against her attorneys" and himself, which Dr. Sadoff thought to be of delusional dimensions and evidence of psychotic thinking. (Id.) He noted that she could not cooperate effectively with either of her legal counsel in preparing her legal defense. (Ex. A-868.) Dr. Sadoff concluded that, while the Defendant had showed moderate improvement on Lithium in terms of her bipolar illness, she required a tranquilizer, in addition to the Lithium, to help control her paranoid ideations. (Id.)

Gerald Cooke, Ph.D., examined the Defendant on April 29, 1985 at which time he conducted a clinical interview and history and administered numerous psychological tests, including the Minnesota Multiphasic Personality Inventory, the Rorschach Inkblot Technique, and various subtests of the Wechsler Adult Intelligence Scale -- Revised/Verbal Subscale. (Ex. 19.) Like Dr. Sadoff, Dr. Cooke found classic signs of hypomanic thinking and behavior during his interview with the Defendant. According to Dr. Cooke, the Defendant "jumped from one idea to another with a classic flight of ideas," was frequently repetitive but unaware of her repetitiveness, maintained an inappropriate affect, evidenced self-aggrandized thinking, and made frequent out-of-context reference to somatic complaints. (Id.) It was noted that, "[m]any times during the history she went off into circumstantial and tangential flight of ideas with rambling and never completed her basic statement or responded to the question that elicited this response." (Id.)

Results from psychological testing, Dr. Cooke found, were consistent with his impression from the clinical interview and history:

The testing reveals Ms. Diehl to be an extremely emotionally labile and emotionally responsive individual who overreacts to the slightest emotional stimulation. Though her affect was hypomanic when I evaluated her, the testing done on the same day indicated a severe underlying depression accompanied by somatic symptoms. The testing also indicated her manic tendencies, and the co-existence of these tendencies simultaneously on the tests is consistent with the diagnosis of Cyclothymic Disorder and/or of Bipolar Illness (manic-depressive illness).

The testing also indicates very tenuous control of impulses, extremely poor frustration tolerance, and a very poor ability to delay gratification of needs and impulses. She has difficulty censoring thoughts and ideas and they emerge in the type of hypomanic ideas described throughout.

Though it is not immediately apparent on interview, the testing also shows a high degree of angry behavior which sometimes crosses the line into paranoid thinking. ... The testing also indicates that she can be very manipulative. She responds to her own needs with little thoughts for the feelings and needs of others and, when this is backed up by her generally negative perception of others, she can rationalize her behavior. (Ex. 19.) Although the Defendant was not overtly psychotic during Dr. Cooke's evaluation, he felt that she was capable of psychotic-like losses of control and that this impression was supported by both the objective and projective personality testing. (Id.) According to Dr. Cooke, "[t]he testing clearly indicates that strong stimulation in the area of nurturance needs, sexuality, and/or anger can lead to psychotic-like episodes in which she is unable to control her feelings and behaviors." (Id.) Though the Defendant had tested in the bright-normal to superior range of intelligence, Dr. Cooke cautioned that this level of intellectual functioning was being measured in a way that was conflict free, and "though she may show good memory and judgment on intellectual tasks where her emotions do not interfere, those situations where she is emotionally involved can produce confusion, poor judgment, and inadequate memory." (Id.)

In summary, Dr. Cooke opined that the Defendant had "shown the seeds of severe mental illness" since her early childhood and that there was a sufficient basis, both in her history and testing, to justify a diagnosis of bipolar disorder. (Ex. 19.) He noted that it was difficult to state whether her mood swings would lead her to the point of psychosis, "involving either loss of contact with reality and/or psychotic misperceptions of reality." (Id.) Though she had not been psychotic at the time of his evaluation, the Defendant's performance on the psychological tests evidenced, to Dr. Cooke, "a potential for decompensation into psychotic behavior." (Id.) He concluded that she was "borderline incompetent" to stand trial in that her illness prevented her from rationally assisting her attorney in her defense, and he therefore recommended that she be treated with both medication and therapy. (Id.)

Defendant was examined by David Paul, M.D. on some 64 occasions between August 1, 1984 and September 3, 1987, while she was lodged at the Erie County Prison. (Ex. A-875.) Dr. Paul's many evaluations of the Defendant were at the request of prison staff, as he was the prison's psychiatrist at the time. (Ex. A-869; Ex. E-6.) Eventually, the trial court ordered Dr. Paul to examine the Defendant and render an opinion as to her competency to stand trial. (Ex. E-9.) Pursuant to Dr. Paul's request, the court also appointed Ted Urban, Ph.D., to perform psychological testing and to assist Dr. Paul in forming an opinion as to the Defendant's competency. (Ex. E-8.)

In a report dated August 1, 1985, Dr. Paul provided a summary of his evaluations of the Defendant. Following his initial evaluation of the Defendant, his Axis I impression was Bi-Polar Affective Disorder, Hypomanic phase. (Ex. A-871.)

A pervasive theme throughout this report is Dr. Paul's observations of the Defendant's manipulative tendencies. He notes, for example, that he evaluated the Defendant on January 16, 1985, at which time she was tearful and angry throughout the interview and ventilated about her fears of court and her supposedly inept legal representation. (Ex. A-871.) Dr. Paul characterized her as "somewhat manipulative" and observed that she "seemed to be trying to enlist my sympathy regarding how she claimed to be being treated." (Ex. A-872.) He further noted that the Defendant spontaneously sought his advice as to whether or not it would be to her advantage to be psychiatrically hospitalized, which prompted Dr. Paul to remind her that he could not appropriately render legal advice. (Id.) As Dr. Paul described in his report: "[i]t was around this point in time that the patient began relating to me primarily in a manipulative manner. She seemed to see me as the person to contact to influence changes in prison policy on her behalf or, alternatively, to secure mental hospitalization for her." (Id.) Dr. Paul noted, however, that none of the Defendant's letters were psychotic; rather they were "well put together and well reasoned." (Id.) Dr. Paul also recited an incident in February of 1985 wherein the Defendant wrote him a letter, ostensibly in an attempt to get Dr. Paul to intervene with prison authorities on her behalf regarding matters of prison discipline. (Ex. A-872-873.) Dr. Paul noted that "[a]t this period of time, she was clearly being manipulative and did not seem to need me for my customary function." (Ex. A-873.)

Dr. Paul provided a follow-up report to the court on September 3, 1987. In that report, Dr. Paul noted that the Defendant had been cooperative, for the most part, during his 64 visits with her, but at times she had displayed psychotic features -- such as pressured speech and flight of ideas -- compatible with her diagnosis of Bipolar Affective Disorder, Circular Type. For most of this time the Defendant had been on medication which, according to Dr. Paul, did not make a significant difference in her presentation but did to some degree control her overt psychotic features. (Ex. A-875.) She had been on Lithium Carbonate from July of 1985 until April of 1987 when, due to the fact that the Defendant was being placed on a diuretic, her continued use of Lithium became hazardous and it was therefore discontinued. (Ex. A-875.)

Throughout his associations with the Defendant, Dr. Paul observed her abnormal suspiciousness of others as a "constant factor." (Ex. A-875.) He described each session as characteristically beginning with the Defendant's critique of her attorneys, whom she would portray as uncaring, unwilling to visit her or take her phone calls, dishonest, and hostile. (Ex. A-876.) According to the Defendant, her attorneys had accepted a substantial sum of money from her parents and wished to place her in a mental hospital so that they could keep the money and wash their hands of her. (Id.) Dr. Paul also noted reports from the Defendant's attorney, Mr. Ambrose, that the Defendant's refusal to answer some of their questions was making the construction of an adequate legal defense virtually impossible. (Id.) Accordingly, on July 28, 1987, Dr. Paul sat in on a meeting between the Defendant and her defense team. He documented his observations as follows:

The patient began this phase of the proceedings by venting great hostility toward her attorneys, calling them liars who want her in a mental hospital and stating that she didn't trust them, but stayed with them only because they have her money. This hostility tended to subside as the proceedings progressed, and she apparently surprised them by answering questions she had refused to answer in previous conferences. Her explanations tended to be complex, circuitous and rather confusing. She seemed to have no worries at all about her own credibility in court.

One of her attorneys pointed out that she had given false answers on a document in which the choices were "yes" or "no". [sic] She rationalized having done this on the basis of her perception of the clerk who presented her with the form as being "bored, stupid and non-professional" and that the form itself was "foolish" and, therefore, lying was alright. When attorneys faced her with the fact that she had, indeed, lied, she became angry and defensive and conducted a short monologue, the essence of which was that her attorneys were not much brighter than the clerk and that Dr. Sadoff is a "quack", [sic] who can't understand her situation, who lies at her attorneys' request, and whose professional qualifications are irrelevant.

When specifically questioned about things known to have happened, she tended to ramble and her logic was weak.

She displayed no pressure of speech. She was markedly paranoid, but not globally so. She was neither euphoric nor delusional. Her judgment was grossly defective.

(Ex. A-877.)

Dr. Paul concluded that, while the Defendant suffered from Bipolar Affective Disorder, Circular Type, she was neither depressed nor grossly psychotic. He cautioned, however, that "this only pertains when the pressure is minimal." (Ex. A-877.) He noted that the Defendant "has the typical manic's capacity for terribly poor judgment" and added that her "literality" hinders her ability to defend herself in court by causing her to freely state such things as her belief in astrology or voodoo without any understanding of the impression that might leave with a jury. (Id.) He closed by opining that, based on her illness and problems with self control and judgment, she was "quite incompetent" to stand trial and did not possess any substantial ability to attain competence in the foreseeable future. (Ex. A-878.)

Upon Dr. Paul's request, the trial court also ordered the Defendant to undergo psychological testing by Ted Urban, D.Ed. (Ex. A-881; E-940, 980.) Dr. Urban examined the Defendant on two occasions in August of 1987. As part of his examination, Dr. Urban conducted a clinical interview and history with the Defendant, obtained a thorough history from Dr. Paul and Mr. Ambrose, and administered numerous psychological tests.

In his August 31, 1987 report to the trial court, Dr. Urban found that all the signs of hypomanic thinking and behavior were still strongly present in the Defendant. (Ex. A-884.) He observed in the Defendant an extreme flight of ideas with much tangential and irrelevant thinking. He noted that the Defendant's "ideas accelerate quickly once her guard is reduced by any stimuli or reference that causes feeling or emotion" and, once triggered, these emotions literally run away with her, causing her to quickly lose all sense of meaning or perspective and resulting in a "complete breakdown of rational thought to a point where she is totally lost and unable to get to the goal of thinking." (Id.) He noted that the Defendant's paranoid delusions were powerful and constantly reinforced and collided with her hypomanic thinking, with the result that even relatively innocuous subjects would become distorted in her mind. (Id.) Test results suggested to Dr. Urban that the Defendant is "highly prone to fake poorly in regular efforts to manipulate and influence others to her own selfish needs." (Id.) In fact, Dr. Urban found these efforts so poorly disguised as to be easily recognizable and confusing to other people. (Id.) Though the Defendant was not felt to be psychotic at the time of her evaluation, Dr. Urban felt that a psychotic loss of control in her perceptions could be easily triggered due to the extreme degree of her internal conflicts. Thus, he found "constant signs of potential for decompensation into psychosis with minimal pressures or when her hypomanic thoughts and feelings accelerate and reality boundaries are blurred." (Id.) He described her as "capable of [presenting] a good social facade and making a good initial impression," but predicted that "the manipulative, psychopathic features will surface in any longer interactions or under the slightest stress." (Id.)

Based on his evaluation, Dr. Urban diagnosed the Defendant with Bipolar Affective Disorder, Hypomanic Phase (Axis I) and Cyclothymic Personality Disorder (Axis II). (Ex. A-885.) He concluded that the Defendant continued to be severely impaired by her emotional disorder and that her impairment permeated all areas of emotional controls as well as her capacity to function or relate adequately to others. "Closer, more meaningful or intense emotional contacts," he felt, would "result in greater distortion to her reactions." (Id.) Moreover, "[i]f circumstances do not meet with her momentary, fleeting emotional need, her responses work to produce constant distortion." (Id.) Dr. Urban concluded that the Defendant was incapable of providing any objective account of her behavior and lacking in any ability to participate rationally and competently in her own defense. (Id.)

On September 4, 1987, the trial court held a hearing to determine the Defendant's competence to stand trial on charges of murder in the death of Robert Thomas. (Ex. E.) Both Dr. Paul and Dr. Urban testified at this hearing.

During his direct examination, Dr. Paul reaffirmed Defendant's diagnosis of Bipolar Affective Disorder. (Ex. E-955.) He testified that, while the Defendant may not have been grossly psychotic in terms of being either manic or openly depressed during his evaluations, "that picture could change with startling repetivity if she were put under enough pressure." He explained that a vigorous cross-examination would probably produce that pressure. (Ex. E-957.) Dr. Paul further related that, when he observed the Defendant during her meeting with her attorneys, the stress of that meeting caused her judgment to become impaired due to her mental illness. (Id.) He agreed that the application of stress to the Defendant, in light of her illness, would cause an increase of impaired judgment and inability to stay on track. (Ex. E-958.) Dr. Paul testified that the Defendant has limited insight into the nature, extent, and severity of her illness and, while she may sincerely believe that she can control herself and her symptoms, she is in fact unable to do so. (Ex. E-960.)

Based upon his observations of the Defendant on more than 64 occasions, his observations of her interactions with her attorneys, his consultation with Dr. Urban and a review of Dr. Urban's findings, Dr. Paul opined that the Defendant could not rationally and meaningfully interact with counsel in the preparation of her case and in giving testimony at trial. (Ex. E-960-961.) Considering the level of hostility which the Defendant had shown toward her lawyers, Dr. Paul doubted that she would be able to cooperate with them. (Ex. E-976.) He noted that the Defendant would likely be amenable to an attorney who would say nice things to her and avoid the hard aspects of trial preparation. (Ex. E-976-977.) As Dr. Paul explained, "[s]he wants to go to trial. If an attorney were to step forward right now and say, 'We'll do it, we'll have you in trial next Wednesday,' I'm sure you would be welcomed with open arms," even though to do so would be against her best interests. (Ex. E-977.)

Dr. Urban similarly opined at the competency hearing that, as a direct result of her mental illness, the Defendant was totally unable to rationally and meaningfully interact with her counsel and provide meaningful testimony in defense of her case. (Ex. E-985, E-992.) Dr. Urban described her psychological problems as "extremely severe" and her mental profile as "a very complicated picture" involving the confluence of three separate disorders. (Ex. E-985.) According to Dr. Urban, the Defendant suffers primarily from bipolar disorder, but she also has an underlying personality disorder as well as "very disturbing paranoid kinds of ideation" that constantly interfere with her capacity to perceive the motives of other people. (Ex. E-986.) Dr. Urban explained:

Assuming we were able to successfully control the manic-depressive form of her illness, ... we would still have to contend with the personality disorder which in itself has an awful lot to do with the way that she forms relationships and how meaningful those relationships are and in terms of constant conflict that she experiences internally. Assuming that that was dealt with, we would still be left with the paranoia that is of great concern to her.

(Ex. E-986-987.) Dr. Urban further explained that -- once emotions are triggered in the Defendant -- even in a non-stressful situation, this has very disruptive effects on her capacity to remain insightful and rational and thus to provide any kind of suitable judgment. (Ex. E-991.)

Following the September 4, 1987 competency hearing, the trial judge found the Defendant not competent to stand trial, but he also found a substantial probability that she could attain competency in the foreseeable future with direct and continuing psychiatric care. He therefore ordered that the Defendant be placed at Mayview State Hospital in Bridgeville, Pennsylvania for continued treatment, and he directed that the court be given periodic reports on her progress. (Ex. E-1043-1044; Ex. 16, 17.)

Mayview State Hospital Records

Defendant was committed to the Forensic Unit of Mayview State Hospital on September 17, 1987. (Ex. A-540.) Upon her arrival, psychological and psychiatric evaluations were performed by Howard P. Friday, Ph.D., and Duncan Campbell, M.D., respectively. (Ex. A-538-541.) Initially, the Defendant presented as pleasant, cooperative and appropriate in her responsiveness and behavior, with clear and coherent speech and no evidence of pressured speech or altered psychomotor activity. (Ex. A-541.) Dr. Friday observed that, during this initial assessment, the Defendant was working very hard to present herself in the best possible light. (Ex. A-539.) Dr. Campbell's initial diagnosis was Bipolar Affective Disorder, Mixed Type in Remission and Mixed Personality Disorder. (Ex. A-541.)

Although the Defendant appeared to be doing well during her first few weeks at Mayview, her behavior soon deteriorated. Shortly following her admission she complained of side effects from her medication and requested that it be reduced. (Ex. 17.) A few days after her medication was discontinued at the end of September, she became agitated and irritable. (Id.) A visit with her parents on September 30, 1987 went badly, ending in verbal altercations. (Ex. 16.) Thereafter, the Defendant was frequently observed on the telephone using profane language toward her mother. (Id.) She became argumentative, demanding and markedly obsessive-compulsive about her appearance. (Ex. 16, 17.) She required significant supervision and redirection to comply with rules and regulations and became sorely resentful of this. (Id.) At the beginning of November she became increasingly grandiose and paranoid and her reasoning and judgment became markedly impaired. (Ex. 17.) She began to display rambling and pressured speech as well as loosened associations. (Id.) At this point, Drs. Friday and Campbell felt that Defendant did indeed manifest the symptoms of bipolar disorder, mixed type and that, while competent upon her arrival to Mayview, she was no longer so. (Id.)

At the beginning of November, 1987, the Defendant was placed on Tegretol and, shortly thereafter, was started on a highly structured and rigid program to address her obsessive-compulsive behavior and to help her become more compliant with ward regulations and routines. (Ex. 17.) She was also involved in regular individual and group psychotherapy and, on this routine, she did improve. (Id.) However, the Tegretol was discontinued in late December due to severe side-effects. Thereafter, the Defendant continued with her behavioral programs and individual therapy and it was felt that her controls and behavior remained ...

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