Marcus Druery Article 46.05 Motion (Diane Mosnik, Ph.D. Preliminary Report) (REDACTED)

Diane M. Mosnik, Ph.D.
Clinical Neuropsychologist Licensed in Texas (#3-1547) & Wisconsin (#2620-057) TEL: 832.483.9732 EMAIL: 4dmosnik@gmail.com
Preliminary Forensic Psychological / Neuropsychological Evaluation July 10, 2012 RE: Review and evaluation of records and administration of a psychological / neuropsychological examination for a preliminary determination of psychiatric diagnoses at present and to form a preliminary opinion of his current mental state, as well as to determine his competency to be executed. NAME: CAUSE No.: DATE of BIRTH: DATE of EXAM: DATES of REVIEW: REFERRAL SOURCE: Mr. Marcus Druery TDCJ # 999464 Cause No. 03-00001-CRF-85; State of Texas vs. Marcus Druery 11/20/1979 05/14/2012 -- 05/15/2012 05/01/2012 -- 07/01/2012 Katherine C. Black and Gregory W. Wiercioch
Evaluation Procedures: The following documents and records were reviewed as part of this assessment and evaluation: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Texas Department of Criminal Justice: UTMB records, July 2011-May 2012, various excerpted pages. Riverside General Hospital, Drug Rehabilitation medical records, #0013317-0013427. College Station Medical Center records, #0014482-0014545. Affidavit of Dr. Terry Rustin, #0007670-0007684. Deposition of Dr. Terry Rustin, Volume 4: 1-53. A two-page report of an evaluation completed by Dr. Kit W. Harrison dated June 3, 2009, from evaluation completed on April 24, 2009, and raw data #0013873-0013923. School records from Bryan Independent School District, #0013949-0013994. School records from Texas State Technical College, #0020001-0020007. Texas Department of Criminal Justice, Windham School records, #0013944-0013947. Texas Department of Criminal Justice: #0014362-0014433. Texas Department of Criminal Justice: #0014334-0014480. Grievance Records, General Grievances, Grievance Records, Medical Grievances,
Texas Department of Criminal Justice: Use of Force records, #0017613-0017768. Texas Department of Criminal Justice: Classification and Records, #0020522-0020557. Texas Department of Criminal Justice: Law Library records, #0020560-0021597.
Preliminary Competency Evaluation, RE: Marcus Druery
15. 16. 17. 18. 19. 20. 21. 22.
Brazos County Jail records, #0020008-0020519. Selected Non-Privileged Letters from Marcus Druery. University Pediatric Association, Medical and Psychiatric records, # 0014246-0014257. St. Joseph Regional Health Center Medical records, # 0014258-0014361. Texas Department of Criminal Justice: UTMB records, Set 1 (through July 2011) and index, pages 1-77 #00016000-0017612. Blinn College records, # 0021600-0021610. ITT Tech records, #0021611-0021612. Scott & White medical records for Mary Druery (paternal grandmother), various excerpted pages, #1-89
Neuropsychological/Psychological Evaluation. The following standardized tests were administered to Mr. Druery on Monday & Tuesday, May 14-15, 2012: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Clinical Diagnostic Psychiatric Interview. WRAT-IV Reading test to estimate premorbid verbal ability. Wechsler Adult Intelligence Scale-IV edition. Wechsler Memory Scale-Revised version Logical Memory Stories and Visual Reproduction subtests. Rey-Osterreith Complex Figure Copy Test. Controlled Oral Word Association with Lexical and Semantic Fluency. Trail Making Test A & B. Wisconsin Card Sorting Test. Tower of London. Brief Psychiatric Rating Scale (BPRS). Scale for the Assessment of Positive Symptoms. Scale for the Assessment of Negative Symptoms M-FAST Interview.
In rendering the preliminary opinions expressed below, I am relying on the information provided to me in the above listed documents and records, the information obtained from the clinical interview and neuropsychological / psychological assessment completed directly with Mr. Marcus Druery on May 14-15, 2012, and upon my professional training as a clinical neuropsychologist, including my special training and experience in the clinical diagnosis of schizophrenia, my 12 years of independent practice combined with my previous 12 years of training in the fields of psychiatry and neurology, to support my opinions in this case.
Introduction. Mr. Marcus Druery was referred for a forensic neuropsychological / psychological evaluation by his current counsel, Ms. Katherine C. Black and Mr. Gregory W. Wiercioch, to determine the status of his mental health at the present time and to determine whether or not his mental health diagnosis has an impact in regards to his competency to be executed. At the time of the initial evaluation, Mr. Druery was a 32 year old, left-handed, African-American male with a completed high school education and approximately 2 years worth of college credits. He is currently residing on Death Row in Texas subsequent to a conviction for capital murder occurring on or about October 31, 2002. He was arrested on November 14, 2002. Mr. Druery was interviewed and tested by this examiner in a small room in the Texas Department of Criminal Justice Polunsky Unit in Livingston, Texas. Mr. Druerys attorneys were not present during the interview or assessment. Prison guards were located immediately outside of the testing room, but were not present inside the testing room. Mr. Druerys ankle shackles remained in place but his wrist shackles were removed so that he was able to participate fully in the testing procedures. At the beginning of the interview and assessment, Mr. Druery was advised of the procedures and the purpose of the evaluation and informed of his right to consent or refuse participation in the evaluation. He was informed that the evaluation was being conducted to gather information about his current mental health status in order to determine whether or not he met criteria for a clinical mental health diagnosis, as well as to determine his competency for execution at the request of his current defense attorneys. He was informed that he would not be provided with any therapy or treatment at any point during the assessment. He was informed that he could choose not to answer any questions or to terminate the evaluation at any time he so chose. Mr. Druery was informed that the evaluation would not be confidential and that it would be shared with his attorneys, any applicable courts, and potentially other individuals involved in his legal proceedings. Mr. Druery agreed to participate in the clinical interview and testing procedures, and was able to paraphrase back to the examiner an understanding of the procedures to be completed during the visit. Relevant Background Information. Mr. Marcus Druery reported that he is the oldest child, with two younger sisters, approximately 6 and 10 years younger, born to the same parents, Ray and Donna Druery. He resided with his family in Bryan, Texas, until he went away to school after graduating from high school in 1997. He reported that he received average to good grades during elementary and high school, stating that he had never been diagnosed with any type of specific learning disability or attention deficit hyperactivity disorder. He stated that he never received special education during his formal schooling. Moreover, there is no documentation of his receiving any academic accommodations or special educational services throughout his formal schooling. Records from the 11th grade of high school indicated that he received grades of a B- average. However, his performance on formal standardized statewide and national testing revealed weaknesses in the areas of language, including language expression and mechanics, and mathematical computations, and concepts and applied problems. Records, including the Comprehensive Tests of Basic Skills from the 6-7th grade, Differential Aptitude Tests from the 8th grade, and PSAT/NMSQT scores from the 11th grade, revealed low average performances in verbal and language abilities, as well as in math skills. Reading has always fallen within the average range for his age. Records from 3rd 5th grades revealed average performances
across academic skills, including reading and language skills, although math computation skills fell in the below average range for his age even at that time. Because of failing English and physical education, Mr. Druery had to complete summer school classes following 9th grade in order to achieve an adequate number of credits to be promoted on to 10th grade, which he was able to achieve through summer school without being held back. Mr. Druery graduated from high school with a C grade average. After graduating from high school, Mr. Druery attended college at ITT technical institute in Austin from November 1999 to January 2000, when he elected to withdraw without completion of any college credits. He attended Blinn College in the spring of 1998 but withdrew without completion of any credits; he again attended Blinn College in the spring of 2002 but received grades of F in both courses he was enrolled in and received no college credit and was placed on academic probation. Later, Mr. Druery attended Texas State Technical College in Waco, Texas, in the field of electrical construction with a major in industrial maintenance technology from September December of 2002, prior to his incarceration. In regards to employment, during his high school and college years, Mr. Druery worked in a corner store in retail and worked for his fathers tire business reportedly off and on for eight years in total. Relevant Family History. According to her medical and psychiatric records, Mr. Druerys paternal grandmother was given a diagnosis of Panic disorder with agoraphobia, Generalized Anxiety Disorder, Dysthymic Disorder, Depression, Somatization Disorder, and Schizoid Personality Traits, and was variously treated pharmacologically with Pamelor (nortriptyline, a tricyclic antidepressant), Elavil (amitriptyline, a tricyclic antidepressant), Celexa (a selective serotonin reuptake inhibitors or SSRI), Mirtazapine (an antidepressant), Xanax (alprazolam, a benzodiazepine used for treatment of anxiety) and Librium (used for treatment of anxiety and agitation). She also carried a medical diagnosis of thyroid disease status post surgery (unknown type). Medical History. In terms of his medical history, Mr. Druery reported a history of hypertension, tachycardia, and thyroid disease. According to the record of the TDCJ Texas Uniform Health Status Update, medical history notes a skin condition first observed on 04/06/2005, tachycardia first observed on 06/28/2005, cellulitis / abscess first observed on 04/27/2006, and hyperthyroidism first observed on 05/16/2006 with Graves disease identified on 05/30/2007, and iatrogenic hypothyroidism being identified on 02/24/2011. His most recent TSH (thyroid stimulating hormone) level taken by Correctional Managed Care was high at 5.85 on 09/30/2011 (normal reference range in US labs is typically considered to fall within the range from 0.5 - 4.5/5.0), indicating that his thyroid is underactive (causing his pituitary to signal an increase in production of the thyroid hormone via TSH, which then shows up as being elevated). He was also noted to have mild proptosis (bilateral bulging of the eyes), often associated with thyroid disease, more specifically Graves disease. Mr. Druery reportedly underwent ablation of the thyroid with radiation (date unknown). Recent physical medical exams by Correctional Managed Care have also indicated peripheral edema, both pedal (in the feet and lower legs) and pitting (i.e., the swelling of body tissues due to fluid accumulation that results in a pattern of pitting of the skin). He reported that he suffered from headaches for which he took medications during middle and high school. On a doctor outpatient visit note dated 09/20/1995, he was diagnosed with possible migraines and asthma. According to medical records obtained from University Pediatric Association, on August 12, 1997, Mr. Druery was
reportedly involved in a motor vehicle accident during which he was the seat-belted driver of an automobile that rear-ended another vehicle. During the accident, he reportedly hit his head against the steering wheel but he did not experience any loss of consciousness. He did reportedly develop a headache. Following the accident, he did not present to the ER. He reportedly slept well the night following the accident, but awoke the next morning with a headache and back pain, so he reported for a doctor outpatient visit. Physical and neurological examination at the office visit on the day following the motor vehicle accident were within normal limits according to the medical record. According to medical records from St. Joseph Regional Health Center, on 02/23/2001, Mr. Druery presented to the ER following involvement in a motor vehicle accident with two rollovers in which he was the seat-belted driver. He was positive for alcohol and urine drug screen was positive for cannabinoids and phencyclidine. Mr. Druery presented with left-sided pain, abrasions to his right arm, and complaints that the back of his head was hurting. There was no evidence or documentation of loss of consciousness; his Glasgow Coma Scale score in the ER was 15/15 and he was not given a diagnosis of head injury or concussion. A C-spine completed on 02/23/2001 revealed no fracture or dislocation. According to medical records from St. Joseph Regional Health Center, on 06/13/2001, Mr. Druery presented to the ER after falling off a motorcycle about 20 minutes prior to presenting to the ER. He was wearing a helmet. He presented with abrasions to the right arm, left hand, and left leg, but there was no evidence to indicate a head injury and there was no loss of consciousness. A CT scan of the head was not ordered or completed as it was not indicated by Mr. Druerys presentation. He was reportedly positive for alcohol but negative for drugs. Physical and neurological examination completed at that time (06/13/2001) were within normal limits in terms of motor and sensory functioning and the patient was fully oriented with no nausea or vomiting or visual disturbance. According to medical records from St. Joseph Regional Health Center, on 12/03/2001, Mr. Druery was a seat-belted passenger involved in a motor vehicle accident that resulted from a tire that blew out. According to the medical record, he reportedly woke up in the car in the woods. Mr. Druery presented to the ER with multiple abrasions and lacerations to the right side of his head, face, and right upper extremity and hand, including a laceration to his right ear and right hand and arm. In addition, he suffered a mild traumatic head injury with brief loss of consciousness and concussion (diagnostic code 850.5, referring to concussion with loss of consciousness of unspecified duration). He also complained of neck pain and left knee pain. In the ER, he obtained a Glasgow Coma Scale score of 14/15, with spontaneous eye opening, and intact ability to obey commands, but mild confusion was noted on the verbal domain. He was also noted to be alert, but demonstrating mildly slurred speech. A CT scan of the head was reportedly within normal limits. A C-spine completed at the time (12/03/2001) revealed sclerosis and hypertrophic changes involving the anterior ring of C1 and the lateral aspect of the odontoid on the right suggesting an old injury, but no evidence of acute fracture was identified. X-rays also revealed the presence of two soft tissue foreign bodies embedded in Mr. Druerys right hand and right wrist. According to medical records from College Station Medical Center, on 12/29/2001, Mr. Druery presented to the ER in a reported catatonic state due to poisoning by unspecified drug or medicinal substance, possibly marijuana with PCP and +/- embalming fluid. After taking the substance, he reportedly presented with catatonia and paranoid delusions. He was generally uncooperative and rarely responded to questions, or if so, with only limited words, and he also expressed paranoid delusions of persecution to his family members prior to becoming catatonic. According to the medical record, he was acting paranoid and he stated to his family that someone was trying to kill him, and then he stopped speaking and his jaw was twitching.
He also exhibited emotional changes and appeared angry. In the ER, he was not responding to his environment well. The symptoms reportedly began on Christmas Eve and then improved on Christmas Day such that he returned to his normal state, but then symptoms recurred on the evening of 12/28/2001, with possible second exposure to the substance, although this was unknown for certain. He was also given secondary diagnoses of druginduced organic delusional syndrome, accidental poisoning by unspecified drug, cocaine abuse unspecified use, and cannabis abuse unspecified use. In the ER, orders were given for him to be treated pharmacologically as needed with Ativan (0.5 mg orally every 6 hours as needed for agitation), Ativan (0.5 mg intravenously every 6 hours as needed for agitation), or Haldol (2-5 mg intramuscularly every 6 hours as needed for agitation), and Tylenol (650 mg, every 4-6 hours as needed for the management of pain). Over the course of the night, he presented with waxing and waning symptoms. According to medical records from College Station Medical Center, on 10/20/2002, Mr. Druery presented to the ER with complaints of losing his voice and agitation after ingesting of some illegal drug, possibly ecstasy about one week prior to presenting to the ER. His parents reported in the medical record that he had been speaking constantly, was hyperactive, and was easily agitated. On discharge, he was given a diagnosis of drug abuse psychosis-acute. No medical documentation is known to exist indicating a history of strokes or transient ischemic attacks, heart disease including myocardial infarctions, diabetes, seizures, autoimmune disorders, major infections such as hepatitis or meningitis, or any history of any neurological condition, such as a movement disorder like multiple sclerosis or Parkinsons disease. Although Mr. Druery has no medical documentation or history of symptoms consistent with any neurological condition, including movement disorders like Parkinsons disease or ALS, he reported repeatedly to this examiner that he believes he has Parkinsons disease and ALS (Lou Gehrigs disease) and that they were caused by his thyroid disease and a wound he believes he sustained in his neck from a gunshot wound purportedly received on the night of the offense. He also believes that his thyroid disease was caused by the purported gunshot wound to his neck. Although Mr. Druery attempts to show this examiner the area that he believes was wounded by a purported gunshot, this examiner cannot discern any area of visible damage to the skin. When queried further by this examiner about his symptoms and his explanation of their existence, his explanation became increasingly disjointed and illogical. When the illogicality of the explanation was pointed out to Mr. Druery, he became distressed, but maintained his disjointed story despite being unable to account for its inconsistencies. It appeared that this belief that he has a neurologically-based movement disorder may be a somatic delusion. Medications. At the time of the interview and assessment, Mr. Druery was taking Enalapril Maleate (20 mg, is a long-acting angiotensin converting enzyme inhibitor medication indicated for the management of hypertension, i.e., high blood pressure), Metoprolol (50 mg b.i.d., is a beta1selective [cardioselective] adrenoceptor blocking agent indicated for the management of hypertension), Hydrochlorothiazide (50 mg, a diuretic with antihypertensive actions, used in the treatment management of hypertension), Levothyroxine (0.05 mg increased from prior dose of
0.025 mg sometime between 02/19/2012 and 04/19/2012; a synthetic form of thyroid hormone used to treat hypothyroidism), and Potassium Cl (10 MEQ; a metal halide salt composed of potassium and chlorine used to prevent or treat low blood levels of potassium, also known as hypokalemia). According to TDCJ/UTMB records, beginning on November 4, 2009, through September 2010, Mr. Druery was prescribed Risperidone (1 mg twice a day; an orally taken antipsychotic medication indicated for the treatment and management of schizophrenia). On October 11, 2010, Mr. Druery was prescribed Risperidone (1 mg to be taken in the evening). On November 18, 2010, the dose of the prescribed Risperidone was increased to 2 mg to be taken in the evening. Mr. Druery was prescribed Risperidone (2 mg to be taken in the evening) from November 18, 2010, through February 16, 2011, on which date the Risperidone was discontinued. On February 16, 2011, he was started on a prescription for Haldol (1 mg, one tab oral taken twice daily; an antipsychotic medication indicated for the treatment of schizophrenia as well as other psychotic conditions), which was increased to 5 mg twice daily on February 24, 2011. On February 16, 2011, he was also started on prescription Haldol Decanoate (100 mg/ml, 100 mg taken intramuscularly every four weeks; an injectable form of the antipsychotic medication indicated for the treatment of schizophrenic patients who require prolonged parenteral antipsychotic therapy; injectable medications are typically utilized for prompt control of the acutely agitated schizophrenic patient with moderately severe to very severe symptoms [reference RxList drug index]). The Haldol medications, in both the orally administered form and the intramuscular injection form, were continued through August 5, 2011, according to the records; no discontinuation date for the medication was noted. Compliance rates for the prescribed medications were significantly variable over time and were largely unknown or not reported. At the time of the assessment, he had not taken any prescription psychotropic medications for the treatment or management of a mental illness. ALLERGIES: He was reported to be allergic to Penicillin. Association of Thyroid Disease with Psychiatric Symptomatology. There is extensive medical evidence that both hyperthyroidism (often the result of Graves disease) and hypothyroidism (which can result iatrogenically, that is, caused by medical treatment, following treatment for Graves disease, e.g., hyperthyroidism, via ablation of the thyroid) can result in a wide range of psychiatric and cognitive symptoms. Hypothyroidism has been associated with an atypical form of depression or dysthymia (kind of chronic low-level depression), a cycling bipolar presentation of mania and depression, or a psychotic disorder, typically presenting as a paranoid psychosis. Cognitively, the patient with hypothyroidism may show impaired attention, impaired concentration, and impaired learning and memory, as well as psychomotor slowing, and/or mental dullness. The patients often show hypersomnia (increased sleep), fatigue, lethargy, anergia, apathy, and low libido. Patients with hypothyroidism also often show weight gain with difficulty losing weight, bradycardia, dizziness, dry skin, edema, and constipation. Individuals with severe hypothyroidism can present with agitation, anxiety, paranoia, and aggressiveness. Severe cases can exhibit a gross impairment of cognition with development of hyperarousal, yelling, cursing, and loosely conceived paranoid delusions. The symptoms of hypothyroid psychoses seem to be the most pronounced in patients who suddenly change from hyperthyroidism to hypothyroidism, including patients undergoing
treatment for hyperthyroidism with radioiodine ablation, those receiving excessively high doses of anti-thyroid drugs, or those following surgery. Patients with Graves' disease often have symptoms of anxiety, nervousness, fluctuating moods and irritability that resolve when thyroid hormone levels return to the normal range. Hyperthyroidism also causes multiple and varied neurobehavioral and psychological changes including anxiety, dysphoria, emotional lability, insomnia, and occasionally episodes of intellectual dysfunction. Concentration may be impaired, and patients tend to speak rapidly, expressing disjointed thoughts. Motor activity is often increased and usually associated with agitation. Rarely, the behavioral changes that can occur in patients with hyperthyroidism may progress to a nonspecific psychotic illness with bizarre delusional thoughts, usually of a paranoid nature. However, in this case, the cognitive clouding often present during hyperthyroidism suggests that the psychotic changes observed at that time are directly correlated with evidence of the delirium that is present rather than attributable to a primary psychotic episode (reference: Whybrow & Bauer, 2000.) According to medical records reviewed, Mr. Druery was exhibiting an elevated level of TSH more than sufficient to produce biochemical hypothyroidism based on his last available level (09/30/2011). More specific blood tests looking at free circulating serum T4 and T3 can provide a much more accurate picture of the functioning of the thyroid (one would typically discover low serum T4 and T3 with elevated TSH). Notably, individuals with free T3 in the lower 20% of the normal reference range are typically cause for concern in those who are exhibiting mood or psychotic symptoms (reference: Geracioti, 2006). However, the same medical research data discussed above indicates that it is rare for individuals suffering from hypothyroidism to exhibit signs of psychosis and even when they do, the symptoms exhibited are usually paranoia and loosely held paranoid delusions. Moreover, the symptoms associated with the thyroid imbalance most often present acutely and are alleviated with treatment of the thyroid; the course of the psychiatric symptoms in hypothyroidism is linked with thyroid levels. Furthermore, hypothyroidism has not been associated with causing other, and much more common, symptoms of schizophrenia, including auditory and visual hallucinations, persistent, firmly held delusional beliefs, or formal thought disorder, that is, a breakdown in the thought processes of individuals with schizophrenia. As such, it is my preliminary opinion in the case of Mr. Druery that hypothyroidism, which appears to be present, at least as indicated by the most recent levels of TSH reported in his record from September 30, 2011, may be contributing to or exacerbating the mental health and physical symptoms he is reportedly experiencing, but would be unlikely to be the sole or primary cause of a diagnosis of schizophrenia, given his total symptom presentation. Psychiatric History. According to the record of the TDCJ Texas Uniform Health Status Update, a diagnosis of schizophrenia, undifferentiated type, was first observed in Mr. Druery on 10/30/2009, and a diagnosis of schizophrenia, paranoid type, was discussed in a note dated 11/28/2011. Mr. Druery was reportedly seen by the Outpatient Mental Health Service through Correctional Managed Care on July 14, 2011, and prescribed Haldol (5 mg oral), Haldol decanoate (100 mg/ml intramuscular injection), and Benadryl (50 mg) for a diagnosis of schizophrenia, undifferentiated type; however, he was noted to be noncompliant with psychotropic medications. He was noted to be not very communicative and to deny mental health symptoms and the need for treatment. He has been approached at cell-side on a monthly basis from 2009 to the present, although he most often refuses to participate in the mental
health visits. Notes report that Mr. Druery continues to present with paranoia and with possible delusions, but that he generally denies the presence of all symptoms. On 01/28/2011, he was referred to Jester IV to Diagnostic and Evaluation (J-IV D & E) for evaluation due to lack of compliance with mental health medications and appointments, poor ADLs (that is, poor ability to adequately complete his activities of daily living including managing his personal care needs and basic hygiene needs), increase in disciplinary cases, and verbalizing odd, inappropriate requests and responses to prison staff. According to the records of his mental health history, he first presented to mental health services on 09/24/2004 with complaints of feeling depressed, over-eating, no sleep, and anxiety. He was again interviewed by mental health on 08/05/2005 for complaints of lack of sleep, but did not show for the follow-up appointment with psychiatry on 01/06/2006. He was assessed by psychiatry on 01/12/2006 but was given no diagnosis. He has a history of only one known suicide attempt in prison consisting of a hanging gesture in 2008. He was referred to inpatient psychiatry on 03/31/2009 but again received no diagnosis. During this period of time, Mr. Druery was evaluated by Dr. Kit Harrison, who documented the presence of hallucinations and delusions with paranoid ideation and depression. He reported that Mr. Druerys affect and cognition had been notably flat and blunted. Notes also indicated that Mr. Druerys family and attorney at the time had independently observed what appeared to them to be a deterioration in his level of functioning, with confusion and apparent cognitive dysfunction. He was sent to J-IV D&E on 11/04/2009 after presenting with disorganized rambling and confusion. At that time he was diagnosed on Axis I with schizophrenia and prescribed Risperdal. He was then treated at Jester IV on the partial remission psychotic track (PRP), until discharged on 05/26/2010. During his inpatient stay at J-IV, he presented with fair hygiene and grooming, and neutral mood with congruent affect, although he was noted to exhibit inappropriate smiling. It was documented that his thought processes, as evidenced by his speech, were odd and he appeared to have developed some delusional beliefs that others were against him and trying to keep him in jail. At that time, he had stated that he had been wired for release and some put his wires back on so he could not be released and he stated that he felt his father was trying to keep him in jail by short-stopping my mail and threatening my life. The examiner at that time also reported observing the presence of formal positive thought disorder in that his speech was notable for derailment and disorganization. He was also noted to be exhibiting some difficulty concentrating and he reportedly became increasingly agitated with discussion of his family, whom he believed was working against him. He was oriented at that time and his intellectual skills, though not directly assessed, were felt to fall in the average range. The mental health examiner at that time reported content was negative for visual and/or auditory hallucinations. Mr. Druery reportedly received benefit from pharmacological treatment while on the inpatient service, but reportedly denied medications as an outpatient. Throughout his inpatient stay, he exhibited waxing and waning of his psychotic symptoms, presenting with relative clarity on some occasions, and with confusion, mild disorganization, paranoid delusional responses, and mild depressive symptoms on others. While on the inpatient service, Mr. Druery stated: they refused to unwire me from speakers; I was hooked up to speakers system. I do not know who did it, when, where, and why. I thought I was supposed to go back to world. I know danger was coming from other inmates, and officers at unit of assignment, as they were trying to attack me from last two years. In 2009, I was stabbed and cut with razors. I do not know what month. I do not hear any voices. He admitted to being noncompliant with prescribed medications. It was felt that his symptoms were possibly exacerbated by lack of control of his environment (due to incarceration). He was felt to meet diagnostic criteria for Schizophrenia, paranoid type. He was again referred to J-IV for lack of compliance with treatment, bizarre statements, and poor ability to complete activities of daily living. He agreed to inpatient
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treatment again on 02/03/2011. He was noted to have a constricted range of affect and paranoid, suspicious delusions, with poor judgment and poor insight. He was also noted to exhibit mild ideas of reference and persecution with conviction. He exhibited conceptual disorganization. He was diagnosed with Schizophrenia, undifferentiated type, r/o Schizophrenia, paranoid type. TDCJ mental health records indicated that the mental health professionals evaluating Mr. Druery considered diagnoses of mood disorder NOS, and bipolar disorder with psychotic features; however, the records indicated that his modal diagnosis has been schizophrenia, undifferentiated versus paranoid type. A diagnosis of Antisocial Personality Disorder was also noted in his medical record update as being first observed on 03/31/2009 and 11/18/2010. Diagnostic criteria for Antisocial Personality Disorder as documented in the official Diagnostic and Statistical Manual of Mental Disorders-4th edition, indicates that a diagnosis of Antisocial Personality Disorder cannot be made unless the occurrence of antisocial behavior is not exclusively during the course of schizophrenia or a manic episode. In addition, it should be noted, that engaging in specific acts of criminal behavior, in and of itself, does not fulfill criteria for a diagnosis of Antisocial Personality Disorder. In order for a diagnosis to be made, one has to show a pervasive pattern of disregard for and violation of the rights of others occurring since 15 years of age. It is unclear that Mr. Druery meets criteria for such a diagnosis. History of Substance Use. In regards to prior substance use, Mr. Druery reported that prior to his incarceration he consumed alcohol excessively and used illicit drugs. Based primarily on a review of the records, including the College Station Medical and St. Joseph Hospital medical records, the affidavit of Dr. Terry Rustin, the deposition of Dr. Rustin, and records from the drug rehab program at Riverside General Hospital, given that Mr. Druery currently exhibited a limited ability to accurately report his substance use history, he has a history of recreationally using various addictive chemicals since the age of 16 years, including alcohol, cannabis, cocaine, methylenedioxymethamphetamine, phencyclidine, benzodiazepine sedatives, prescription opioids, and tobacco. According to Dr. Rustin, Mr. Druery presented information that met criteria for dependence on drugs, although he did not specify the extent of use of any of the individual substances. According to Dr. Rustins evaluation, Mr. Druery admitted to using alcohol, cannabis, methylenedioxymethamphetamine, and phencyclidine on October 31 and November 1, 2002, including the use of fry sticks. Dr. Rustin obtained this information from Mr. Druery during his face-to-face meeting with him on 03/14/2006 on the Polunsky Unit. In Dr. Rustins deposition, he stated that he believed Mr. Druery had a pretty long-term history of using PCP and that he had substantial abuse of a large number of drugs. He stated that the drug of choice prior to, and at the time of, the offense appeared to have been PCP. He further stated in his deposition, that the long-term mental consequences [of PCP use] are brain damage it kills brain cells, and the evidence suggests that long-term use leads to a schizophrenia-like condition. In addition, he stated that many of the symptoms of schizophrenia are replicated by the use of this drug. He also reported that the resultant brain damage from long-term use primarily involves the frontal lobe and the median forebrain bundle, an area of the brain that controls moods, emotions, and personality, so that people become easily agitated, potentially aggressive, and changeable in their mood.
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Mr. Druery received outpatient drug and alcohol rehabilitation from June 3-5, 2002, and was then transferred to a residential treatment program to receive treatment for the dependence on, and reported abuse of, alcohol (noted to be his primary substance of choice), marijuana (noted to be his second drug of choice), and PCP (his tertiary drug of choice), according to the medical records from Riverside. He was sent to rehabilitation at the recommendation of the criminal justice system for charges relating to the manufacturing and distribution of crack cocaine; however, at the time of the recommendation, Mr. Druery was not claiming a substance abuse problem and his screening interview (06/06/2002) revealed only a slight [substance abuse] problem, treatment probably not necessary. At the beginning of treatment, he was noted to be stable and attentive and had not used substances in the preceding month; he had been in jail at the time. Records from the treatment program provided no evidence that Mr. Druery abused alcohol or illicit drugs to the degree that he was experiencing any physical signs of dependence, withdrawal symptoms when not using the substances, or medical conditions associated with heavy substance abuse, including seizures, black-outs, or heavy tolerance. Mr. Druery did not reportedly use any substance, including alcohol, cannabis, or PCP, on a daily basis at any point in his history. He reportedly did not hide his use of the substances, did not use any of the substances first thing in the morning, but used them in a recreational manner. Mr. Druery participated in the residential drug treatment program from 06/05/2002 to 07/02/2002. He was diagnosed with alcohol dependence and cannabis abuse. On Mr. Druerys discharge summary under the heading assessment of clients progress toward goals was written, no progress; however, no further details were available. During the rehabilitation program at Riverside, he did not endorse, and was not observed to be, exhibiting any signs of a depressed mood, agitation or anxiety, hyperactivity or distractibility, suicidal ideation, flat affect, hallucinations, or delusional beliefs. Moreover, he was not noted to be exhibiting any indication of cognitive dysfunction or abnormal thought processes or memory problems. According to his records, there have been no other legal problems associated with his substance use, including no history of DUI or public intoxication charges. Association of Substance Use with Schizophrenia and Psychosis. While many research studies have examined the relationship between substance use and the experience of psychotic symptoms, a review of the literature suggests that a variety of substances, including alcohol, cocaine, amphetamine, phencyclidine, methylenedioxymethamphetamine, and cannabis, can mimic the presence of psychotic symptoms in users while intoxicated or during withdrawal phases, but are unlikely to be responsible for causing full-blown psychotic syndromes in individuals who have no pre-existing vulnerabilities to developing schizophrenia. Research also indicates that individuals with premorbid signs or vulnerabilities for developing psychosis, including a family history of psychosis, exhibit higher rates of substance use than the general population. The literature indicates that substance abusers are at a higher risk of developing psychosis and psychotic patients are at a high risk of developing the tendency for substance abuse. Moreover, violence, aggression and crime are known to be more frequent among persons who have both psychotic symptoms and tendency for substance use than either alone. The literature also shows that individuals with substance use and severe mental illness have been associated with a host of negative outcomes, including, but not limited to, a poor response to treatment, clinical instability, poor overall adjustment, treatment non-compliance, and violent behavior.
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Based on a comprehensive review, Boutros and Bowers concluded that the literature strongly suggests that a number of drugs of abuse, specifically psychostimulants, hallucinogens, and cannabis, alone or in combination, can cause or enhance susceptibility for a state of chronic psychosis. Substance abuse is a common condition antecedent to a first psychotic episode, suggesting that it may be a risk factor for the onset of a primary psychosis. Rosenthal and Miner have devised a statistical model that discriminates between substance-induced psychosis and schizophrenia in patients who have both psychoactive substance use disorders and prominent delusions or hallucinations. Formal thought disorder and bizarre delusions were found to be key predictors of schizophrenia, while suicidal ideation, intravenous cocaine abuse, and a history of drug detoxification or methadone maintenance showed an inverse relationship with schizophrenia (reference: Caton et al. Journal of Psychiatric Practice 2000; 6:256-266). Methamphetamine users family loading for schizophrenia proportionately increased the likelihood of their developing psychosis and similarly influenced the length of psychosis postabstinence. It is possible that those with a high family loading for schizophrenia tend to start using methamphetamine earlier in their lives and use it more heavily. This in turn might lead to the development of more severe and prolonged psychotic symptoms. Certain N-Methyl-Dasparate (NMDA) glutamate receptor agonists like phencyclidine have long been known to produce psychotic states with features of schizophrenia including delusions, hallucinations, thought disorder and negative symptoms. This observation contributed to the NMDA hypothesis of schizophrenia. Recent experimental studies using subanaesthetic doses of ketamine resulted in dose-dependent production of neuropsychological defects, positive symptoms and thought disorder. In another study, Krystal et al. investigated the interactive effects of ketamine with amphetamine on healthy volunteers. As expected, ketamine produced positive and negative symptoms, thought disorder and impairment in executive functions, and amphetamine produced positive symptoms, thought disorder and psychomotor activation. When given consecutively, the drugs had an additive effect on the production of thought disorder, less than additive effect on psychotic symptoms and no interaction in causation of negative symptoms. Amphetamine reduced the cognitive impairment produced by ketamine. The review suggested that psychosis in the aftermath of substance abuse is fairly common. Some substances are more likely to be associated with greater risk of psychosis, namely, cocaine, amphetamines, cannabis and alcohol. The propensity to develop psychosis appears to be a function of the severity of use and of dependence. Family loading for psychosis and personality diatheses have important contributions to the development of psychosis (reference: Thirthalli & Benegal, Current Opinion in Psychiatry 2006, 19:239245). A paper by Hall and colleagues evaluates three hypotheses about the relationship between cannabis use and psychosis in the light of recent evidence from prospective epidemiological studies. These hypotheses are that: (1) cannabis use causes a psychotic disorder that would not have occurred in the absence of cannabis use; (2) that cannabis use may precipitate schizophrenia or exacerbate its symptoms; and (3) that cannabis use may exacerbate the symptoms of psychosis. There is limited support for the first hypothesis. As a consequence of recent prospective studies, there is stronger support for the second hypothesis, as four recent prospective studies have found relationships between the frequency with which cannabis had been used and the risk of receiving a diagnosis of schizophrenia or of reporting psychotic symptoms. These relationships are stronger in people with a history of psychotic symptoms and they have persisted after adjustment for potentially confounding variables. The absence of any change in the incidence of schizophrenia during the three decades in which cannabis
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use has increased makes it unlikely that cannabis use can produce psychoses that would not have occurred in its absence. It seems more likely that cannabis use can precipitate schizophrenia in vulnerable individuals. There is also reasonable evidence for the third hypothesis that cannabis use exacerbates psychosis (reference: Hall et al., Drug Alcohol Rev. 2004 Dec;23(4):433-43.). Kovasznay and colleagues found that a lifetime history of substance use disorder seemed to influence the course of illness at six-months for subjects with a diagnosis of schizophrenia, but not for those with a diagnosis of affective psychosis. The subjects diagnosed with schizophrenia and a history of substance use disorder were found to have poorer functioning at six-months, as reflected by the Global Assessment of Functioning scores both for worst functioning in the past month and for best functioning during the six-month interval. In addition, the group diagnosed with schizophrenia had worse Brief Psychiatric Rating Scale (BPRS) scores, suggesting more symptomatology, although the increase in symptoms was not reflected in differences in either the Scale for the Assessment of Positive Symptoms global score or the percentage with hallucinations or delusions at six-months. The higher level of symptomatology was revealed in the study despite the lack of significant differences in treatment experience by both patient groups during the study interval (reference: Kovasznay et al., Schizophrenia Bulletin, 1997). In the case of Mr. Druery, there is not enough evidence to support a direct causal link between his use of psychoactive substances and the development of psychotic symptoms. Moreover, there are no records to indicate that he has had access to, or abused, any substances since his incarceration during which time he has exhibited the most severe symptoms of psychoses, enough to warrant a diagnosis of schizophrenia. In addition, the information available in the records regarding Mr. Druerys past substance use does not indicate a pattern of consistent daily use and abuse of illicit drugs or alcohol (see substance use history above). Most substance-induced psychotic symptoms are considered to be short lived and to resolve with sustained abstinence along with other symptoms of substance intoxication and withdrawal. In psychotic patients who use substances, evidence for independence of psychotic symptoms requires onset of symptoms during a drug-free period or persistence of psychotic symptoms during a period of sustained abstinence from psychoactive substances (when intoxication or withdrawal effects can no longer account for psychotic symptoms). Except for alcohol-induced pathological dementia (which has not been diagnosed in the case of Mr. Druery), all the substance-induced psychotic mental disorders are considered to be time limited (reference: Rounsaville, Schizophrenia Bulletin, 2007). However, individuals diagnosed with schizophrenia who have a comorbid history of substance use or past history of substance abuse disorder typically have a poorer prognosis and greater severity of illness that is more difficult to treat pharmacologically. Criminal History. Mr. Druery reported that during his adolescence he engaged in some minor criminal behaviors, including running away from home, fighting, petty theft, and drug use. He was on juvenile probation for having a hand gun on school property. While completing the drug rehabilitation program in June 2002 upon recommendation of the criminal justice system relating to charges of manufacturing and distributing crack cocaine, Mr. Druerys record indicated that up to that point, he had received two arrests for drug related charges and one arrest for a weapons
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offense, for a total lifetime incarceration/detention of five months, including the month prior to his entry into rehabilitation. According to records from the TDCJ Classification and Records, Mr. Druerys DPS report indicated a history of eight arrests; Mr. Druery reportedly admitted to 11 arrests, resulting in three juvenile detentions, including carrying a weapon on prohibited premises, unlawful carrying of a weapon, possession of marijuana violations, a criminal trespass, and a charge for manufacturing and distribution of crack cocaine. He reportedly also had court recommended commitments to outpatient treatment for narcotic abuse (1998) and inpatient treatment for drug abuse (2000 at the Barbara Jones Rehab Center in Houston; and 06/2002 at Riverside residential treatment program). Current Clinical and Behavioral Observations by This Examiner. Mr. Druery was accompanied to the room within the prison that was to be used for the assessment by three armed prison guards. He was shackled at the wrists and ankles and wearing standard issue prison coveralls. After being admitted to the examination room, his wrist shackles were removed, but his ankle shackles remained fastened. The door to the room was locked from the outside, where prison guards stood watch. The room was well lit from artificial lighting, barren of decoration, and contained two single chairs and a small table. This examiner and Mr. Druery were seated at an angle opposite each other adjacent to the small table. A large window comprised one of the walls in the room so that the prison guards could fully observe the activity within the room. Typically one or two guards were present at this window and observed the testing procedures throughout the examination. Despite occasional distractions by the guards, Mr. Druery was able to attend fairly well to the assessment procedures. The ambient temperature of the room was cold but not unbearable. Apart from the above-mentioned distractions, Mr. Druery was awake, alert, and generally oriented to time and location. He accurately stated the current month and year, but approximated the date as middle of the month. He was able to name his current defense attorney. He was also able to accurately report basic personal information, including his date of birth, age, and educational attainment although he couldnt accurately report the dates of his post-high school college attendance, and he had difficulty reporting an accurate time-line of his life experiences. He presented as an obese, African-American man measuring 73 inches tall. He presented with what appeared to be poor hygiene as body odor was apparent. He appeared older than his stated age. He reported being left-handed. He stated that he needed prescription glasses but did not wear them for the assessment. He did not require hearing aids. Vision and hearing appeared adequate to complete the testing procedures. His mood appeared neutral, neither obviously dysphoric or euthymic, but his affect was blunted and significantly restricted in range. His facial expression was very flat and there was a definite lack of affective responsiveness. He exhibited essentially no changes in his facial expression, regardless of the topic being discussed. Expressive gestures were severely limited. He was rigid and exhibited very little change in his body posture. His eye contact was generally direct, although he had a tendency to stare unblinking at this examiner rather than establish appropriate eye contact. At one point during the interview, Mr. Druery stared piercingly at this examiner and queried her as to her mood; asking whether she was angry with him or thinking something in particular about him because he had noticed the color of one of the rings on the examiners fingers. He stated that he thought the color of the ring (i.e., midnight blue) meant something and indicated that it meant the examiner was thinking bad thoughts about him. While querying this examiner, he
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appeared guarded, paranoid, and generally upset; but despite portraying those emotions in his eyes and with his tone of voice, his facial expression changed minimally. Spontaneous conversational speech was variably fluent, and notable for tangential and illogical responses that were often fragments rather than complete sentences. His speech was slow in rate, with no evidence of pressure, and prosody was markedly reduced. Volume was variable, though generally decreased. Although Mr. Druery attempted to maintain logical and goaldirected responses, his thought processes were notable for tangentiality, a clear loosening of associations, derailment (slipping off one idea onto another), and loss of his train of thought. His thought processes were also notable for illogicality, wherein the logical pattern of his speech could not be followed and did not reach logical conclusions. His speech became much more disjointed and illogical when discussing his medical symptoms and his interpretation or perspective of what was happening to him, as well as his current beliefs about what had transpired at the time of the offense. Mr. Druerys thoughts were at times distracted by internal and external stimuli that altered or interrupted his flow of speech. He often looked at the guards standing at the window of the meeting room and would mumble to himself. At one point, he asked this examiner if the guards were talking about him and described to the examiner that the guards would play tricks on him and were wiring him to the speakers which could follow him around the prison. On day 1 of the assessment, Mr. Druery did not strongly believe that the speakers had followed him into the testing room, but on day 2 of the assessment, he reported that they were present and that he was wired. Observation of Mr. Druery by this examiner on two occasions during the assessment indicated behaviors exhibited by him that suggested that he might be attending to some sound (or voice) other than this examiners, as he would avert his gaze upward slightly and would mumble under his breath. When queried by the examiner about what he said, he denied that he had said anything. When questioned directly about whether he had heard a voice talking to him, he said that he did not have hallucinations, that the people in the prison really were wiring his head to speakers and talking to him and listening to him. During the assessment, Mr. Druery reported directly that he heard voices and that those voices did tell him to do things, but theyd say it over the speaker or something, or the officers would tell me. He stated that the other inmates knew he was hearing things from the speakers, so that meant it was real. He further stated that the reason he had received disciplinary action was because he was jacking the slot [of his cell] to turn off the speakers. In addition, Mr. Druery endorsed the experience of hearing a loud radio playing during the daytime when there was no radio present near him. He stated that he hears music and talking, mostly coming from the vents, like even at Jester IV, it followed me there [the speakers and wires]. He also endorsed the experience that sometimes it seemed like somebody controlled his symptoms, turning them on and off, so that he would not know how he will feel most days. He stated that at those times, he is sitting there and he feels unclear-minded or hell feel sick all of a sudden. He stated that he has a lot of symptoms that just come out of the clear blue sky some days. He stated that he has felt things crawling on him when there was nothing there, including stating that he had that experience yesterday. However, he could not elaborate on what he thought that sensation was. There was also evidence of poverty of content of speech, with some responses being overly vague, concrete, and not directly responsive to the questions posed. Mr. Druery was typically limited in the length of his responses. It should be noted that tangentiality, derailment, distractible speech, and illogicality are signs of positive formal thought disorder and most commonly associated with a diagnosis of a schizophreniaspectrum disorder. As a result of the presence of this formal thought disorder, it was, at times,
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difficult to follow Mr. Druerys line of thinking. It was particularly difficult to follow his line of thinking in regards to his explanation of his involvement in the offense. Rather than offer a plausible, defendable explanation for his behavior, the defendant puts forth a disjointed, illogical explanation that cannot be clearly understood, let alone proven or supported by the evidence available in the case. Moreover, Mr. Druery insists that he does not have a mental illness and is not in need of any pharmacological treatment for a mental illness, despite reportedly benefiting from pharmacological treatment while on the inpatient unit at J-IV. Although Mr. Druery did not endorse the experience of auditory or visual hallucinations upon direct questioning, his behaviors and the content and form of his thought processes met criteria for the presence of both positive and negative symptoms of psychosis. Although he insisted that he did not hear voices talking to him, his behaviors in his cell and within the prison, support the presence of auditory hallucinations, ideas of reference, and thought broadcasting. Mr. Druery reported that his brain has been wired to speakers in his cell and throughout the prison so that others can hear his thoughts and talk to him. During the interview and assessment, he reported to this examiner that the other inmates can hear him talking in his cell but he stated that he is not concerned about this because he knows that they know that he is wired and that he is actually talking through the speakers. He reported that the speakers follow him through the prison even when he leaves his cell. Despite the fact that he could offer no explanation of who did the wiring or how the wiring and the speakers could follow him throughout the prison, even though they could not be detected, he could not be dissuaded from his belief. Moreover, his belief and description of this wiring has been consistent across setting and over time. His writing also reveals evidence of his disjointed and illogical thought patterns. His comment to this examiner during the assessment, indicating that he believed the color of a ring the examiner was wearing meant that she was thinking something about him, suggesting the possibility of an idea or delusion of reference, such that insignificant remarks or events in the environment, in fact, refer specifically and directly to him and connote some special meaning in regards to him and his legal case. It also appears that he may be experiencing a variety of somatic delusions, that is, unrealistic beliefs that somehow his body is diseased, abnormal, or changed (see the medical section above). Of particular importance was the overriding presence of Mr. Druerys persecutory delusional beliefs. He exhibited a well-developed, though illogical, fixed, and firmly held delusional system comprised of persecutory delusions regarding his life in the prison and his involvement in the offense for which he was convicted. At the time of the interview, Mr. Druery was preoccupied with his delusional ideation which he often interjected unbidden during the testing procedures. He appeared unable to differentiate isolated facts from his interwoven delusional explanation for his circumstances, as well as the status of his health. Mr. Druery was unable to discuss or explain the circumstances that led to his arrest and conviction without reference to delusional ideas and his persecutory explanation for his situation. While he was able to state that he was on death row and that he had been to trial for capital murder, he firmly holds that he did not commit the offense and is not going to be executed, despite being able to state that an execution date has been scheduled. While he states that an execution date has been scheduled, he becomes confused because he knows that he is not guilty and that he was supposed to have been freed already; he becomes agitated when trying to explain, and help himself to understand, why he has not been freed when he was promised that he would be. He does not assert that the scheduled execution date is for crimes that he is responsible for committing. He is also very distressed that evidence that he believes exists in his defense has not been presented to the court and used to free him. He is convinced of this and believes
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it so strongly that he becomes visibly agitated when trying to explain it, clearly not understanding why things have not worked in his favor. Moreover, he stays true to his explanation no matter how disjointed and illogical it is, and even when the illogicality is pointed out to him and questioned by this examiner. In regards to his motor functions, Mr. Druerys gait was within normal limits and he ambulated unassisted. No other abnormal motor movements were observed during the assessment period, although Mr. Druery himself complained of experiencing tremor in his upper extremities (none was observed by this examiner). On testing, his performance was perseverative but not impulsive. He was cooperative with testing procedures and appeared motivated to perform to the best of his abilities as he wanted to demonstrate his intelligence to others and he did not want to be perceived as mentally retarded. Insight into his own thought processes and his current legal situation was limited. He appears to have no understanding or awareness of his own mental state and categorically does not interpret his unusual sensory and perceptual experiences as potentially being related to a mental illness or a psychiatric disorder. He is in no way purposefully attempting to portray himself as insane, but reports that he believes his experiences to be real. In fact, when questioned directly about the fact that mental health professionals, such as this examiner, interpret his experiences and beliefs as symptoms of a mental illness, namely, schizophrenia, he stated that he knows that the mental health providers at TDCJ want him to take medications, but he does not believe that he needs to take medications for anything other than his blood pressure and thyroid. Results of Neuropsychological Examination. Brief Review of Cognition in Schizophrenia. The typical age of onset for symptoms of schizophrenia in males ranges from the early- to latetwenties. Neurocognitive deficits are considered to be central to the pathophysiology of schizophrenia, and the neurodevelopmental literature indicates that such deficits predate fullblown psychosis. Individuals diagnosed with schizophrenia may demonstrate an overall lowering of their cognitive capabilities, but typically fall within the average to low average range on measures of general intellectual functioning. However, they display significantly greater deficits on tests of executive functions, working memory/vigilant attention, information processing speed, visual construction, and verbal memory, relative to other cognitive skills. It has been shown repeatedly that patients at risk for developing psychosis and those experiencing the prodromal symptoms of schizophrenia (and later develop psychosis) demonstrate impaired cognitive performance relative to healthy subjects particularly on measures of verbal memory and executive functioning and working memory. Another hallmark feature of schizophrenia is lack of awareness, or insight, into the fact that they have symptoms of a mental illness, have cognitive deficits, or that they need treatment for their beliefs. [references: Rund, Sundet, Asbjornsen, Egeland, Landro, Lund, Roness, Stordal, & Hugdahl. Neuropsychological test profiles in schizophrenia and non-psychotic depression. Acta Psychiatrica Scandinavica, 2006, 113:350-359; Lysaker, Lancaster, Davis, & Clements. Patterns of neurocognitive deficits and unawareness of illness in schizophrenia. Journal of Nervous & Mental Disorders, 2003, 191:38-44; Lencz, Smith, McLaughlin, Auther, Nakayama, Hovey, & Cornblatt. Generalized and specific neurocognitive deficits in prodromal schizophrenia. Biological Psychiatry, 2006, 59(9):863-71.]
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Cognitive Examination Results. Sight reading fell in the average range, estimating at least average premorbid verbal capability. Fund of general knowledge fell solidly in the average range, while verbal abstract reasoning fell in the moderately impaired range for his age. Basic vocabulary knowledge was average for his age, while his comprehension of social norms and customs was low average. Auditory working memory for the repetition of digits fell within the low average range in regards to his ability to recite digits forward and on the more complex tasks requiring working memory to recite digits backwards and in numerical order (raw digits forward=6, raw digits backwards=5, numerical = 6). His ability to recite a series of randomly presented numbers and letters in sequential order and his ability to mentally complete orally presented arithmetic story problems were average for his age. His overall verbal capability fell within the low average range (Verbal Comprehension Index SS = 89, 23rd percentile, range 85-100). His ability to construct three-dimensional blocks to match templates and his ability to solve visual puzzles fell within the borderline range, while nonverbal deductive reasoning fell in the average to above average range for his age. His overall nonverbal, perceptual reasoning skills also fell within the low average range (Perceptual Reasoning Index SS = 88, 21st percentile, range 83-94). Visual processing speed was also low average overall, as measured by his ability to rapidly transcribe symbols to digits and his ability to search for visual targets amidst foils (Processing Speed Index SS = 86, 18th percentile, range 80-94). Overall, his level of general intellectual functioning fell in the low average range (Full Scale IQ SS = 83, 13th percentile, range 80-87). Basic visual motor scanning speed fell within the above average range for his age, but his performance deteriorated significantly on the more demanding component of the task requiring rapid mental set alternation, resulting in a mildly impaired performance and one that required significantly greater proportion of time to alternate between two overlearned sets. Lexical fluency, that is, the ability to rapidly generate words beginning with a certain letter, was low average for his age, while semantic fluency, that is, the ability to rapidly generate exemplars that belong within a specific semantic category, was average for his age. His performance on a test of novel problem-solving requiring the accurate sorting of cards when provided with only limited verbal feedback regarding his performance was impaired and notable for difficulty shifting among alternate solution strategies. His performance on the problem solving task was significantly perseverative. On another, more complex test of novel problem-solving (the Tower of London test) which measures strategic planning skills, he approached the task in a disorganized manner. He completed only 1/10 items in the fewest number of moves and required an excessive number of moves to complete the remainder of the trials. In addition, he committed a number of time-violations, and required an excessive overall total problem-solving time, despite taking time before making his first move. In regard to his memory performance, immediate free recall for the details of two short verbal narratives fell within the average range for his age, while delayed free recall fell in the impaired range, with limited retention of information over time (38% retained). Recognition memory for the details of the stories was intact (19/21 hits). Immediate free recall for a series of four simple geometric designs without rehearsal was average, while delayed free recall of the geometric designs was above average for his age, with excellent retention of information over time (105% retained). Recognition memory was also intact, with no difficulty accurately discriminating actual from distractor items. His ability to accurately copy a complex geometric design was impaired for his age and notable for perceptual and spatial distortion of the design. The examinees total score on the Miller Forensic Assessment of Symptoms Test (M-FAST) fell below the cut-off score, rendering it unlikely that Mr. Druery was feigning or malingering symptoms of a psychosis. Moreover, the symptoms endorsed by Mr. Druery were consistent with common first rank symptoms often experienced by patients suffering from a psychotic disorder. Subjective report of mood
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symptoms did not indicate an endorsement of any symptoms of depression and there was no indication of any suicidal ideation. Summary of Cognitive Test Results and Diagnostic Impression. In summary, Mr. Druerys overall level of general intellectual functioning was assessed and fell in the low average range. His performance on cognitive testing revealed impaired executive functions, impaired attention/working memory, impaired visual construction, and impaired delayed free recall for verbal information, in the context of intact visual perceptual skills and learning and memory for visual information. The pattern and severity of these cognitive impairments would be consistent with those deficits often exhibited by patients diagnosed with schizophrenia and well-documented in the scientific literature. Moreover, the results do not provide any evidence to support a diagnosis of malingering. Mr. Druery refuses mental health visits and is noncompliant with prescribed antipsychotic medications because he does not believe that he has a mental illness. Summary of the Psychiatric Rating Scales (BPRS & SAPS/SANS). A thorough assessment of psychiatric symptoms revealed the presence of both positive and negative psychotic symptoms, including the presence of formal thought disorder. Specifically, Mr. Druery exhibited at least moderately severe delusional thinking characterized by persecutory delusions, as well as what appear to be somatic delusions and delusions of reference and thought broadcasting. Although he did not endorse the experience of auditory hallucinations directly, his descriptions of his experiences relating to his delusional beliefs that he is wired to speakers, includes the experience of people listening and talking to him, as well as him responding to them; suggesting the presence of auditory hallucinations that he attributes to real environmentally produced auditory stimulation rather than hallucinations. In regards to formal thought disorder, he evidenced tangentiality, illogicality, and a loosening of associations, as well as occasional derailment. In regards to the negative syndrome, he evidenced marked unchanging intensity of facial expressiveness, affective nonresponsivity, decreased spontaneous movements, anhedonia, apathy, and poverty of content of speech, with an overall rating of severe affective flattening. Mr. Druery also exhibited emotional withdrawal, conceptual disorganization, and pervasive suspiciousness. He did not exhibit or endorse the experience of tension, anxiety, depression, mania, or excitement. Diagnostic Impression. Given the above information, Mr. Druery fulfills criteria for a diagnosis of Schizophrenia, with features of both paranoid and undifferentiated subtypes. Mr. Druery neither endorses nor presents a history consistent with cycling episodes of alternating depression and mania, despite occasional reports of feeling mildly depressed. However, throughout his medical record, when he presented to mental health his symptoms always included psychotic symptoms and no evidence of a pure episode of major depression, and no indication of any episode of mania or hypomania at any point in his record or history. He therefore, does not meet criteria for a diagnosis of bipolar disorder or a primary mood disorder. Rather, he appears to exhibit the waxing and waning of psychotic symptoms with acute exacerbations resulting in increased symptoms and confusion.
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Review of Prior Neuropsychological Evaluation. Dr. Harrison, in his neuropsychological evaluation dated April 24, 2009 (report dated June 3, 2009), described Mr. Druerys presentation as including a number of delusional facets to this mans thinking (e.g., transient ideas of reference, mixed jealousy, and persecutory beliefs) constituting a mini-paranoid episode. He reported that Mr. Druery had been hallucinating and was slightly delusional with paranoid ideation. His affect and cognition was [sic] notably flat and blunted. He also reported that Mr. Druery exhibited borderline intellectual functioning with low average verbal comprehension skills at that time, as well as exhibiting impairments in working short-term memory, cognitive processing speed, and executive functioning and problem-solving. Dr. Harrison further stated that consonant with his personality style, this man appears to have drifted into a recent psychotic episode marked by periods of regressive behavior, physical impassivity, and the shutting down of emotional expression and behavioral initiative. Dr. Harrison interpreted the results of his evaluation as demonstrating an episode of recurrent Bipolar Disorder, Type 1, most recently depressed phase, but with psychotic features. However, he does not present any history of Mr. Druery that would support such a clinical diagnosis. Specifically, in order for a clinical diagnosis of Bipolar Disorder I to be made, the individual must have a history of at least one manic episode or mixed episode, he must be currently in a major depressive episode (i.e. Mr. Druery must have exhibited signs and symptoms of depression most of the day, nearly every day for a period of at least two weeks consecutively), and the mood episodes are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia or other psychotic disorder (DMS-IV manual, 1994). Within his narrative report, Dr. Harrison presents no data, medical records, or informant information that would support a history of cycling mood episodes. Moreover, Mr. Druerys own medical records indicate that the mental health care he received from Correctional Managed Care beginning in 2009, necessitating inpatient treatment at the JesterIV psychiatric Unit on several occasions, revealed symptoms consistent with psychotic episodes for which a clinical diagnosis of Schizophrenia, paranoid type, would be appropriate, and was indeed eventually made. Importantly, the symptoms described in Dr. Harrisons brief report could be interpreted as being more supportive of a diagnosis of psychosis rather than a primary mood disorder. OVERALL GENERAL IMPRESSION. The thorough record review and direct examination of Mr. Druery by this examiner, detailed above, support the finding that Mr. Druery suffers from a severe, active psychotic condition, meeting criteria for a clinical diagnosis of schizophrenia, undifferentiated with features of paranoid and disorganized subtypes, beginning sometime in his mid- to late-twenties (consistent with the typical age of onset for schizophrenia). It is further evident that Mr. Druery does not now at this time have an understanding of his own mental state or an appreciation of his experiences as symptoms of a mental illness. In addition, the evidence presented above supports the finding that Mr. Druery has no insight into his mental status and a limited understanding or appreciation of his actual current legal situation. Individuals who are seriously mentally ill, such as Mr. Druery, retain the mental capacity for factual knowledge and some ability to remember (depending on the degree of any possible memory impairment) and relate what we would identify as facts regarding a specific event,
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although their memory of an event and their subsequent interpretation of the event can be altered or influenced by their mental illness. In this case specifically, the facts as related by Mr. Druery are intricately and inextricably interwoven with his fixed and rigid delusional system. As such, the facts of the case as presented by Mr. Druery, in comparison to the facts of the case obtained from other records, are severely distorted and, at this time, Mr. Druery does not recognize or rationally understand what the true facts of the case are and what they imply in regards to his current legal defense. It has been clearly documented throughout the records that Mr. Druery sees no other applicable legal posture apart from his delusional beliefs supporting his innocence. I opine with confidence that Mr. Druerys delusional ideas pervade and distort his understanding of his current legal situation and his present circumstances. Because of his inflexible, psychotic, and delusional interpretation of his circumstances, Mr. Druery does not have the capacity to rationally understand the connection between his crime and his punishment. It is the opinion of this examiner that Mr. Druery is rigid, illogical, and perseverative about his ideas. A review of Mr. Druerys mental health records indicates a progressive deterioration in his thought processes and overall level of mental and cognitive functioning. Scientific literature has indicated that the longer an individual diagnosed with psychosis or schizophrenia goes untreated, the more refractory to treatment the disorder will be, with significantly less hope for recovery as time goes on. FINDINGS. In regards to Competency to be Executed. In Ford v. Wainwright, 477 U.S. 399 (1986), the Supreme Court held that [t]he Eighth Amendment prohibits the State from inflicting the penalty of death upon a prisoner who is insane. The Supreme Court determined that the State may not constitutionally execute those, who, because of mental illness, do not rationally understand the fact of their impending execution and the reason for it. Id. at 422 (Powell, J., concurring). In Panetti v. Quarterman, 551 U.S. 930 (2007), the Supreme Court examined the standard that should be applied to Ford claims, endorsing a standard that requires an inmate to have a rational understanding of the reason for his execution. Id. at 959-61. Accordingly, I was asked to assess Mr. Druerys execution competency based on a consideration of the following questions: 1) Does Mr. Druery suffer from a severe mental illness? 2) If so, does Mr. Druerys mental illness interfere with his ability to rationally understand the world around him (i.e., perceiving accurately, interpreting, and/or responding appropriately to the world around him)? 3) If so, does Mr. Druerys mental illness deprive him of a rational understanding of the connection between his crime and punishment? My Recommendation for: Competency to be Executed. This examiner finds that the defendant, Mr. Druery, does currently suffer from a severe mental illness, namely schizophreniaa psychotic disorder, and that this severe mental illness and the resultant symptoms of the mental illness (e.g., delusions, ideas of reference, thought broadcasting, and auditory hallucinations, among others), interfere with his ability
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to accurately interpret, perceive, and respond to the world around him. The severity and nature of the mental illness also deprive him of a rational understanding of the connection between his crime and his punishment. He does not appear to have a rational understanding of his sentence or the punishment that he is about to suffer. Although he has a factual awareness that an execution date has been scheduled for the crime for which he was tried, he does not believe that he will be executed because of his illogical, fixed, and firmly held delusional belief system. Thank you for the referral of this forensic evaluation.
Diane M. Mosnik, Ph.D. Licensed, Clinical Neuropsychologist

Marcus Druery Article 46.05 Motion (Diane Mosnik, Ph.D. Preliminary Report) (REDACTED)

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Diane M. Mosnik, Ph.D.

Preliminary Competency Evaluation, RE: Marcus Druery

15. 16. 17. 18. 19. 20. 21. 22.

Preliminary Competency Evaluation, RE: Marcus Druery

Preliminary Competency Evaluation, RE: Marcus Druery

Preliminary Competency Evaluation, RE: Marcus Druery

Preliminary Competency Evaluation, RE: Marcus Druery

Preliminary Competency Evaluation, RE: Marcus Druery

Preliminary Competency Evaluation, RE: Marcus Druery

Preliminary Competency Evaluation, RE: Marcus Druery

Preliminary Competency Evaluation, RE: Marcus Druery

Preliminary Competency Evaluation, RE: Marcus Druery

Preliminary Competency Evaluation, RE: Marcus Druery

Preliminary Competency Evaluation, RE: Marcus Druery

Preliminary Competency Evaluation, RE: Marcus Druery

Preliminary Competency Evaluation, RE: Marcus Druery

Preliminary Competency Evaluation, RE: Marcus Druery

Preliminary Competency Evaluation, RE: Marcus Druery

Preliminary Competency Evaluation, RE: Marcus Druery

Preliminary Competency Evaluation, RE: Marcus Druery

Preliminary Competency Evaluation, RE: Marcus Druery

Preliminary Competency Evaluation, RE: Marcus Druery

Preliminary Competency Evaluation, RE: Marcus Druery

Diane M. Mosnik, Ph.D. Licensed, Clinical Neuropsychologist

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