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BRAIN RESEARCH LABORATORY
October 12, 1997CASE #: xxxxx
EXAMINED: xxxxxx
SUBJECT: Determination of cognitive, neurological and neuropsychological status of defendant whos is charged with robbery and assault and battery with serious bodily injury..
NEUROPSYCHOLOGICAL EVALUATION
Pursuant to court order under Evidence Code section 1017, and upon the request of his attorney, the defendant (Mr. Q.) was initially interviewed and examined for 2.5 hours in the Santa Clara County Jail and a report issued on xxxxx, which is reported below.
xxxxxx
SUBJECT: Determination of present sanity and mental and neurological status of defendant, ability to form intent, competency to stand trial, assist in his own defense, and understand the nature of the proceedings against him.
FORENSIC EVALUATION
Pursuant to court order under Evidence Code section 1017, and upon the request of his attorney, the defendant (Mr. Q.) was interviewed for 2.5 hours in the Santa Clara County Jail. In addition, a guard was briefly interviewed, jail infraction records and reports submitted by his attorney were reviewed, and portions of an IQ test were administered.
OBSERVATIONS. Mr. Q., a xx year old, well nourished Black male, was informed as to the purpose of the exam including the fact that what ever we discussed was not confidential and would be communicated to his attorney who in turn might release this information to the courts. He indicated that this was understood. Mr. Q. was dressed appropriately, was reasonably groomed and was oriented, alert, and proved to be cooperative, friendly, forthcoming, and socially and emotionally appropriate. There was no overt evidence of delusions, psychosis, auditory or visual hallucinations, or the presence of a formal thought disorder, and he was able to communicate affectively. However, suspiciousness and some elements of paranoia were noted, as well as a modest degree of irritability and anger near the end of the interview. In addition, Mr. Q. admitted to experiencing auditory hallucinations.
PRESENT CRIMINAL CHARGES. Mr. Q. was charged with robbery and assault and battery with serious bodily injury.
DEFENDANT'S RESPONSE TO & EXPLANATION OF CHARGES. Mr. Q. states that it was not his intent to harm the victim. Rather, he states that he had been fired and they had argued about the amount of money he was owed versus the amount the victim was going to pay. He states that the victim finally offered him cash, which he accepted, but that he still threatened to take the victim to the labor board. He states that as he turned to leave, the victim took hold of his arm or shoulder, and that he exploded and pushed the victim away, causing him to fall and severely injure himself. He states also that he attempted to assist the victim because he was frightened and had no intention of harming the victim. In addition, Mr. Q. admitted that he has an explosive temper and that he sometimes loses control of himself and responds violently, especially if he is stressed. He further indicates that an aunt had recently died and that his counseling had just ended when this incident occurred and that he had been feeling stressed, angry and irritable that day.
HISTORY Mr. Q. was born and raised in xxxxxx by his mother and step-father. He states that he had frequent contact with his real father. He states his childhood was rough and that he was frequently physical punished as a form of discipline. He states that his step-father abused alcohol, but denies that he was otherwise abused. Mr. Q. indicates that he may have been exposed to high levels of led as a child, and suffered from attention deficit disorder, hyperactivity, and learning disabilities, and that he was expelled then dropped out of high school in the 11th grade. He later obtained a GED. He has never served in the Armed Forces or completed any college courses.
Mr. Q. states that he has been married once, but that they separated after one year. There were no children, though he has a 4 year old son from another relationship, whom he contacts only rarely.
Mr. Q. indicates that he has been trained as a glazer--a job he has worked at on and off from 1983 to 1991. He had been working a a dishwasher at the time of the above incident. His employment history is spotty due to the time he has spent in jail and prison over the years. He indicates he has been in prison approximately 6 times for various offenses including burglary and at least two assaults.
Mr. Q. enjoys reading, and watches the news regularly. His hobbies include playing basketball.
EMOTIONAL & NEUROPSYCHOLOGICAL FUNCTIONING. Mr. Q. denies alcohol or drug use, but admits to blackouts, seizures, auditory (but not visual) hallucinations, and reports that he has suffered at least 5 significant head injuries involving loss of consciousness. His first head injury was at age 7 when he fell off the roof and landed on his head, and that his last injury was in 1996 when he was knocked unconscious by the police. His seizures began around 1985 and he was placed on Dilantin. Apparently his last seizure was in 1992. He is no longer on anti-seizure medication. He has also been in counseling as a child and an adult, and was admitted to a psychiatric hospital at least once for a suicide attempt. He has been placed on anti-psychotic medication in the past, haldol and elavil, and reports that these drugs reduced his feelings of paranoia, anger, rage,and behavioral outbursts. Mr. Q. reports a history of auditory hallucinations, i.e. voices which are difficult to understand. These hallucinations had their onset in the early 1980's, but ceased in 1992 when he also ceased to have seizures. He also reports paranoia, a heightened startle reaction, memory loss, and deja vu, as well as a compulsion to keep himself clean.
Mr. Q. admits to fits of explosive violence and extreme emotional lability where he sometimes suddenly erupts over even minor or inconsequential irritations. The records from the jail also indicate that he displays paroxysmal episodes of violence. He has apparently assaulted staff and other inmates. The jail personnel consider him extremely dangerous and violent. Similarly, his attorney reports observing episodes of extreme anger coupled with paranoid and accusatory ideation.
These serious and severe disturbances are indicative of obvious neurological impairment, involving the frontal and especially the temporal lobes.
INTELLECTUAL & COGNITIVE FUNCTIONING. Informal evaluation of cognitive functioning suggests that Mr. Q. falls within the Average range of intellectual ability with an estimated IQ of approximately 95 (37% rank). This indicates that approximately 63% of the normative population scores above his level of capability. Although only a partial exam was administered, there is some suggestion that his verbal IQ may be significantly higher than his non-verbal IQ. The screening exam suggests a verbal IQ of 103, and a non-verbal IQ of 87--which is consistent with the possibility of neurological dysfunction involving the right hemisphere.
Mr. Q. has a clear understanding of the judicial process and the role of the judge, jury, the prosecutor and his attorney. He understands the nature of the charges against him and is capable of assisting his attorney in his defense.
IMPRESSIONS, CONCLUSIONS, RECOMMENDATIONS. Mr. Q. is alert, oriented, and of average intelligence. He was able to respond in a rational manner to my questions, is fully cognizant of the charges against him and is able to rationally discuss the incident in question. He also has an understanding of right and wrong. In this regard he is able to assist his attorney in his defense. Mr. Q. also displayed an understanding as to the nature of the judicial process and the role of the judge, prosecutor and his attorney. Hence, in my opinion, Mr. Q. is competent to stand trial within the meaning of the Penal Code section 1368.
It is obvious that Mr. Q. suffers from neurological dysfunction, likely involving the temporal and frontal lobes. He has experienced at least five head injuries involving loss of consciousness, as well as seizures, blackouts, auditory hallucinations, deja vu, paranoia, emotional lability, and paroxysmal fits of extreme, uncontrolled and irrational violence--indications of brain damage (Joseph, 1990, 1996). He also has a history of attention deficit disorder, memory loss, and hyperactivity, as well as exposure to lead as a child. Some of his violent episodes are related to uncontrolled reactions in response to stress, irritation, paranoid feelings, or perceived threat. In yet other instances, he appears to spontaneously react in an uncontrolled fashion for no apparent reason However, he is just as likely to immediately calm down as if nothing had happened, and/or to become worried and regretful about his actions--again indicating extreme emotional lability and a rapid waxing and waning of his mood states. Certainly, as is apparent, these disturbances would greatly interfere with his ability to control or inhibit his impulses, to consider consequences, or to form intent. Moreover, given evidence of abnormal brain activity (the seizures) it is likely these problems would fluctuate and wax and wane in severity and would be more easily triggered when stressed.
It is likely that his brain damage is secondary to and/or has been exacerbated by his repeated head injuries. Exposure to high levels of lead may also be a contributing factor. There may also be congenital factors which would account for the presence of the learning disabilities and attention deficit disorder during childhood. In addition, Mr. Q. reports that a "fatty tumor" was removed from his forehead several years ago, and that it is beginning to grow back. This tumor was heavily vascularized. Given the tendency of tumors to break off, enter the blood stream, and to metastasize to the brain, it is possible that his brain may have been infiltrated by these growths (Joseph, 1990, 1996).
A complete neuropsychological evaluation, and an MRI are recommended to assist in ruling out the possibility of neoplasm. As to possible led exposure as a contributing factor, hair samples could be obtained and assayed to determine if abnormal levels of this heavy metal are, or have been present in his system.
____________________ Rhawn Joseph, Ph.D.
Joseph, R. (1990). Neuropsychology, Neuropsychiatry, Behavioral Neurology (Plenum, NY) Joseph, R. (1996). Neuropsychiatry, Neuropsychology, Clinical Neuroscience (Williams & Wilkins, Baltimore).
October xx, xxxx
Per the request of his attorney, a complete neuropsychological (5.5 hr.) evaluation was performed and Mr. Q. was administered a number of standardized and neurobehavioral measures which have been found to be sensitive to the functional integrity of various regions of the cerebrum. Intellectual, perceptual, attention, visual-spatial, linguistic, somesthetic, memory, reading, math, and conceptual functioning were assessed via the Wechsler Adult Intelligence Scale-revised, Wisconsin Card Sort, Rey Auditory Verbal Learning test-revised, Wechsler Memory Scale, Incomplete Words Test, Auditory Vigilance tasks, Gates-Maginitie Reading Tests-revised, subtests from A. Luria & the Halstead-Reitan and related measures. In addition, police reports, and medical records from Pelican Bay were reviewed. The following is a very brief summary report of the findings.
OBSERVATIONS. Mr. Q., a 33 year old, well nourished Black male, was again informed as to the purpose of the exam including the fact that what ever we discussed was not confidential and would be communicated to his attorney who in turn might release this information to the courts. He indicated that this was understood. Mr. Q. was dressed appropriately, was reasonably groomed and was oriented, alert, and proved to be cooperative, friendly, forthcoming, and socially and emotionally appropriate. There was no overt evidence of delusions, psychosis, visual or auditory hallucinations (though he admits to auditory hallucinations), or the presence of a formal thought disorder, and he was able to communicate affectively. Although some degree of suspiciousness and some elements of paranoia were still noted, this was much reduced compared to the second and especially the first interview
HISTORY Mr. Q. was born and raised in San Francisco by his mother and step-father. He states that he had frequent contact with his real father. He states his childhood was rough and that he was frequently physical punished as a form of discipline. He states that his step-father abused alcohol, but denies that he was otherwise abused. Mr. Q. indicates that he may have been exposed to high levels of violence as well as high levels of led as a child. He claims to have suffered from attention deficit disorder, hyperactivity, and learning disabilities, and that he was expelled then dropped out of high school in the 11th grade. He later obtained a GED. He has never served in the Armed Forces or completed any college courses.
Mr. Q. states that he has been married once, but that they separated after one year. There were no children, though he has a 4 year old son from another relationship, whom he contacts only rarely.
Mr. Q. indicates that he has been trained as a glazer--a job he has worked at on and off from 1983 to 1991. He had been working a a dishwasher at the time of the above incident. His employment history is spotty due to the time he has spent in jail and prison over the years. He indicates he has been in prison approximately 6 times for various offenses including burglary and at least two assaults.
Mr. Q. enjoys reading, and watches the news regularly. His hobbies include playing basketball.
Mr. Q. denies alcohol or drug use, but admits to blackouts, seizures, auditory (but not visual) hallucinations, and reports that he has suffered at least 5 significant head injuries involving loss of consciousness. His first head injury was at age 7 when he fell off the roof and landed on his head, and that his last injury was in 1996 when he was knocked unconscious by the police. His seizures began around 1985 and he was placed on Dilantin. Apparently his last seizure was in 1992. He is no longer on anti-seizure medication. He has also been in counseling as a child and an adult, and was admitted to a psychiatric hospital at least once for a suicide attempt. He has been placed on anti-psychotic medication in the past, haldol and elavil, and reports that these drugs reduced his feelings of paranoia, anger, rage,and behavioral outbursts. Mr. Q. reports a history of auditory hallucinations, i.e. voices which are difficult to understand. These hallucinations had their onset in the early 1980's, but ceased in 1992 when he also ceased to have seizures. He also reports paranoia, a heightened startle reaction, memory loss, and deja vu, as well as a compulsion to keep himself clean.
Mr. Q. admits to fits of explosive violence and extreme emotional lability where he sometimes suddenly erupts over even minor or inconsequential irritations. The records from the jail also indicate that he displays paroxysmal episodes of violence. He has apparently assaulted staff and other inmates. The jail personnel consider him extremely dangerous and violent. Similarly, his attorney reports observing episodes of extreme anger coupled with paranoid ideas. As stated in my report of 8/10/97, these serious and severe disturbances are indicative of obvious neurological impairment, involving the frontal and especially the temporal lobes.
MOTOR. The patient is right handed and observation of spontaneous motor activity indicates the expected tendency to activate the right half of the body more so than the left. Strength, tactile-motor, and finger tapping and oscillation were not evaluated. Across tasks requiring continuous perseverative or 3-step hand movements and when required to perform a "go-no go" (e.g. "When I hit the table palm down, you hit the table with the edge of your hand, he performed in the average to low average range.
SOMESTHESIS & STEREOGNOSIS Crude and two point discrimination appears to be within average limits, as is his capacity to localize touch or recognize common objects tactually explored. Complex stereognostic functioning was not evaluated. However, finger recognition was found to be within average limits.
ATTENTION & CONCENTRATION His ability to maintain simple auditory and attention and concentration was found to be within high average to superior limits, whereas visual attentional functioning appears to be within the low average range. When presented with complex auditory material and when distracted, moderate attentional fluctuations and reductions were noted such that the patient tends to become overwhelmed and distracted when presented with complexity. These deficits are most apparent when required to learn complex paragraph length verbal material (see memory, below). This tendency to become overwhelmed, coupled with related behavioral disturbances, is also suggestive of dysfunction involving the frontal lobes, findings which may seem to be contradicted by his superior ability to maintain attention on certain tasks (e.g. recalling a series of numbers and repeating them backward. However, in some cases of right frontal lobe seizures, or even due to right frontal lobe tumors, the frontal lobes can sometimes become hyperactivated creating a condition referred to as "perseverative attention" (Joseph, 1996).
VISUAL-SPATIAL SKILLS His ability to attend to and differentiate between relevant vs irrelevant visual detail, to solve complex mazes involving spatial-directional skills, to perform tasks requiring visual closure (i.e. gestalt formation, gap filling) or draw and copy complex geometric-like figures is within average to high average limits.
EXPRESSIVE LINGUISTIC SKILLS. Word finding, word knowledge, expressive vocabulary, and articulatory skills are within average limits. Spelling, and confrontive and word finding abilities are within average limits.
RECEPTIVE LINGUISTIC SKILLS All aspects of receptive language functioning, including judgment, common sense, receptive vocabulary and the ability to perform 3-step commands is within average limits. Hence, comprehension appears to be well within normal limits.
READING COMPREHENSION The patients ability to read and comprehend single sentences is within the average range, whereas his ability to recognize incompletely written words is within mildly reduced limits. His ability to understand high school level paragraph length material or to comprehend complex grammatical relationships presented in written format is within the mildly reduced range. Hence, he demonstrates mild disturbances when presented with complex reading material.
MATH An evaluation of arithmetical functioning indicates average levels of ability when presented with auditory, written or standard visual high school level math problems.
MEMORY Long term memory for public events, individuals and facts was found to be in the average range. Immediate memory for simple auditory material or simple sentences is within superior limits. When presented with 15 item verbal lists, the patient was only able to learn and recall less than 70% of the the items (mild disturbance). However, significant and severe levels of forgetting was demonstrated when presented with distraction, and 30-minute delayed memory was found to be moderate to severely reduced.
Immediate and short-term (30-minute delayed) memory for complex verbal narrative paragraphs is moderately reduced as is memory for written passages. Immediate and short-term memory for visual-pictorial material is within average to mildly reduced limits.
Overall, complex and short term verbal (but not visual memory functioning is significantly compromised and indicates a disturbance involving the functional integrity of the left half of the brain, the left temporal lobe in particular.
INTELLECTUAL FUNCTIONING Formal evaluation of intellectual capacity indicates that the patient obtained a Verbal IQ of 101 (52% rank), a Performance-perceptual (non-verbal, visual-spatial) IQ of 95 (37% rank), and a Full Scale IQ of 98 which places him in the Average range of intellectual functioning overall and at the 44% rank. This indicates that approximately 66% of the normative population scores at or above his level of capability. In addition, a
significant degree of subtest variability was noted, with a 14-8 among the verbal measures, and 13-5 among the non-verbal tests (differences of more than 3 points are considered significant). Overall, there is a 9 point discrepancy which indicates that he has likely lost a considerable degree of intellectual capability, and is indicative of cerebral impairment. These results are consistent with his history of head injury, seizures, and learning disabilities.
As noted above, and in my previous report, Mr. Q. admits to blackouts, seizures, auditory (but not visual) hallucinations, and reports that he has suffered at least 5 significant head injuries involving loss of consciousness. His first head injury was at age 7 when he fell off the roof and landed on his head, and that his last injury was in 1996 when he was knocked unconscious by the police. His seizures began around 1985 and he was placed on Dilantin. Apparently his last seizure was in 1992. Similarly, his hallucinations ceased in 1992.
IMPRESSIONS & CONCLUSIONS.
Mr. Q. is alert, oriented, and of average intelligence. Nevertheless, the overall pattern of results is indicative of cerebral dysfunction involving the left temporal lobe in particular. Left temporal lobe dysfunction is indicated by the mild to moderate disturbances demonstrated on complex reading and verbal memory tasks. Temporal lobe dysfunction is also suggested by his history of seizures, auditory hallucinations, deja vu, paranoia, emotional lability, and paroxysmal fits of extreme, uncontrolled and irrational violence (Joseph, 1990, 1996). However, as suggested in my initial report, there is also a suggestion of frontal lobe dysfunction. Although this is indicated by his tendency to lose control and to act in a spontaneous and violently disinhibited fashion, as well as his tendency to become overwhelmed, frontal lobe dysfunction is also suggested by his superior ability to maintain attention when required to recall a series of numbers and repeat them backward. Although this may seem paradoxical, in cases involving excessive frontal lobe activity, such as due to a seizure activity or an irritative lesion, patients may demonstrate what has been referred to as "perseverative attention" (Joseph, 1996). That is, the patient has difficulty shifting attention due to frontal lobe dysfunction.
Hence, the testing results are consistent with his history of cognitive, memory, and emotional disturbances, including his reports of repeated head injury and epilepsy. Exposure to high levels of lead may also be a contributing factor. There may also be congenital factors which would account for the presence of the learning disabilities and attention deficit disorder during childhood. In addition, Mr. Q. reports that a "fatty tumor" was removed from his forehead several years ago, and that it is beginning to grow back. This tumor was heavily vascularized. Given the tendency of tumors to break off, enter the blood stream, and to metastasize to the brain, it is possible that his brain may have been infiltrated by these growths (Joseph, 1990, 1996). Unfortunately, although an MRI was recommended and ordered by the Court to assist in ruling out the possibility of neoplasm, this procedure has not yet been carried out.
In summary, the overall pattern of results are indicative of brain damage involving the left temporal lobe in particular, and possibly the (right) frontal lobe. It is likely that this cerebral and temporal lobe injury is a major contributing factor to his history of episodic and uncontrolled violence and thus significantly interferes with his ability to form intent, or to consider consequences when enraged, and in fact, may be responsible for triggering episodes of violent behavior. Indeed, violence, as well as paranoia, and auditory hallucinations, are commonly associated with temporal lobe dysfunction, and seizure activity commonly migrates to the temporal lobes even if the seizure foci is located in a different region of the brain (Joseph, 1990, 1996).
____________________ R. Joseph, Ph.D. Neuropsychologist
Joseph, R. (1990). Neuropsychology, Neuropsychiatry, Behavioral Neurology (Plenum, NY) Joseph, R. (1996). Neuropsychiatry, Neuropsychology, Clinical Neuroscience (Williams & Wilkins, Baltimore).
ADDENDUM
On xxxxxx, I received the results from the MRI which I had recommended to rule out a space occupying lesion and/or infiltrative growth. The MRI was performed and interpreted by Dr. xxxxxxxx, who stated in his conclusions on page 2, that a "very subtle lesion arising within the right frontal lobe" was discovered, suggestive of a "venous angioma. These sometimes can be associated with seizures." Dr. xxxxxx also raises the possibility of "petechial hemorrage," and as an option suggests a second MRI with a focus on obtaining very thin slice images" in order to make a more definitive diagnosis.
As noted in my report (above) and as based on the findings from the initial and later exams performed by myself, I suggested the possibility of a space occupying lesion in the (right) frontal lobe. A space occupying lesion would account for his seizures, but, as noted, seizure activity can also migrate to the temporal lobes. Seizure activity would not show up on an MRI and even with EEG this is difficult to detect.
Although we do not know at this point the identity of this space occupying lesion, Dr. Trefelner suggests a "venous agnioma." In this regard, it is noteworthy that
angiomas may take the form of an venous malformation (a tangle of blood vessels which may continue to grow in size), but they are also associated with calcification of the glia within the upper layers of the neocortex. Moreover, as noted by Adams & Victor (1994), some angiomas are associated with an overgrowth of connective tissue beneath the skin of the forehead; and, they may pass, via the bloodstream or the cranial nerves, and infiltrate the neural vasculature and neural tissue. Indeed, it was my observation of an unusual connective tissue mass (what appeared to be a fatty tumor) beneath the skin, upon the forehead, which led to my recommendation for an MRI as I suspected infiltration. Moreover, according to Adams and Victor (1994), these angiomas may effect the facial nerve serving the eyelid, and they are sometimes associated with abnormalities involving the upper eyelid. Mr. Q. in fact has variably demonstrated an abnormality involving the upper eye lid ("a lazy eyelid") and according to Adams and Victor (1994), "the involvement of the upper eyelid is of greatest importance and nearly 100% of such cases are associated with cerebral lesions," i.e. brain damage.
Lastly, it must be stressed that obvious lesions must be present to be picked up by an MRI and that additional lesions are likely present.
____________ Rhawn Joseph, Ph.D. (10/21/97).
Adams, R., & Victor, M. (1994). Principles of Neurology (McGraw Hill, NY).
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