January 13, 2004

The Honorable Shirley Troutman
Erie County Court Judge
Erie County Hall
92 Franklin Street
Buffalo, NY 14202

Dear Judge Troutman:

As per your order, Mr. Jeremy Perkins was transferred from Erie County Holding Center (ECHC) to Rochester Regional Forensic Unit (RRFU) on 8/8/03 for a psychiatric evaluation under CPL 330.20 status. He was initially evaluated by Drs. Christopher Deakin and Srinivas Yerneni. You subsequently ordered Mr. Perkins to be examined by two board certified psychiatrists.

IDENTIFYING DATA

Jeremy Perkins is a 30-year-old, single, Caucasian male, who at the time of the instant offense lived with his parents in Amherst, NY. He was arrested on 3/13/03 and charged with Murder, 2^nd Degree, and Criminal Possession of a Weapon, 4^th Degree. He stabbed his mother to death. He was found competent to stand trial and later was found Not Responsible for his charges due to mental disease and defect. He was transferred to RRFU from ECHC under CPL 330.20 Examination Order on 8/8/03 and has remained hospitalized since.

SOURCES OF INFORMATION

1. Review of Mr. Perkins’ psychiatric record at RRFU.
2. Review of CPL 330.20 Examination reports by Christopher Deakin, M.D., dated 9/12/03, and Srinivas Yemeni, M.D., dated 9/29/03.
3. Review of all information as detailed in Dr. Deakin’s CPL 330.20 Examination report.
4. Interviews with Mr. Perkins.
5. I have been involved in Mr. Perkins treatment since the day of his admission to RRFU. As Dr. Deakin’s supervisor, I have been aware about the patient’s psychiatric status, treatment planning, and his response to treatment.

OPINION

It is my opinion, within a reasonable degree of medical certainty, that Mr. Perkins suffers from a dangerous mental disorder. He has responded only partially to treatment so far and continues to suffer from same signs and symptoms of his mental illness as he did at the time of the instant offense. He continues to harbor same delusions and continues to experience auditory hallucinations. His insight or awareness into his mental illness is quite poor.

BACKGROUND INFORMATION

Mr. Perkins was born to Ellen and Donald Perkins and grew up in Buffalo, NY. He has a younger sister. His childhood has been described as uneventful. He required Special Education classes for reading remediation. His family moved to California for two years, but then came back to Buffalo. They report that during his teenage years he was involved in small thefts along with his friends. After graduating from high school, he worked for six months. He subsequently attended course at Erie Community College, but dropped out during the second semester. He reports that alcohol and occasional drug abuse made it difficult for him to continue with his college courses. After dropping out of college, he went to work for his father’s construction company and worked there for six years. It appears that as his mental illness progressed, he was unable to focus and do a good job, and that led to him losing the job at his father’s company. Mr. Perkins has mostly lived with his parents. Two years ago he briefly went to live with some family friends, but returned back to live with his parents due to his ongoing behavioral difficulties. He has mostly been a loner. He has had two short-term relationships.

PSYCHIATRIC HISTORY

Mr. Perkins reports of having suffered from an episode of depression at age 12 that resolved without any medical intervention. The exact onset of his current psychiatric illness is unclear. It appears that he started exhibited early signs of Schizophrenia at age 26, two years prior to the instant offense. He became obsessed with Diane, his sister’s friend. He started believing that he could communicate with her telepathically and she would speak with him through a doll in his room. He also started believing that they had known each other for thousands of years. There was a significant deterioration in his condition in spring of 2002. His behavior became more bizarre, so did his thought patterns. Around this time his performance at his job began to deteriorate. He had difficulty following instructions and was unable to concentrate.

He was arrested on 8/14/02 for Trespassing and Resisting Arrest at University of Buffalo. The police were called when students noticed him acting strangely and looking into cars in a bizarre fashion. He later told the police that he was looking for Diane and thought that she might be in one of the cars. When the police inquired why he was looking for Diane, he replied in a disorganized fashion and became irritated. He challenged the officers to arrest him. While the two officers were arresting him, he fought with them resulting in significant physical injury to one of the officers. He was arrested and later seen by John Treanor, M.D. for CPL 730 Examination. Dr. Treanor noted that he was circumstantial, disorganized, and quite suspicious. Mr. Perkins also believed that he was Jesus Christ and he would laugh and smile inappropriately. He was found not competent to stand trial and the court ordered him transferred to Erie County Medical Center (ECMC) Psychiatric emergency room. His mother (the victim of the instant offense) convinced ECMC staff that he did not need to be hospitalized and that she would look after him. Following his discharge, he continued to display bizarre and inappropriate behavior. He was again taken to the hospital by his parents on 8/21/02 and seen by neurologist who recommended psychiatric treatment. Patient’s parents ignored this advice and instead sought help from Church of Scientology.

From September 2002 until the instant offense in March 2003, Mr. Perkins’ condition continued to deteriorate. During this period he was being treated by a Church of Scientology physician, who diagnosed him to be suffering from Schizophrenia, but believed that the cause of Schizophrenia was toxins related to some bacteria in his intestines. He did not receive proper medications and instead was being treated with variety of over-the-counter vitamins. Meanwhile, his condition was deteriorating and he started misperceiving his environment, including his belief that his mother was devilish. He continued to become more and more suspicious and fearful of others.

INSTANT OFFENSE

Mr. Perkins murdered his mother by stabbing her 77 times on the morning of 3/13/03. He had been actively psychotic for months and that day was “like any other day.” His mother had tried to force him to take 10-15 vitamins pills, which he did not want to consume. She also made him take a shower and clean himself against his wishes. At some point Mr. Perkins became enraged, picked up a 12-inch knife and started stabbing her while she was on the phone talking with a friend. He stabbed her 77 times. He also reported trying unsuccessfully to cut her right eyeball because “her eyes were evil.” However, Dr. Horowitz’s report suggests that the autopsy did not suggest any significant damage to the victim’s right eyeball.

TREATMENT COURSE SINCE INSTANT OFFENSE

Mr. Perkins was transferred to ECMC soon after his arrest and was evaluated by Drs. Bakhai and Gokhale. The physicians noted that he believed that he was Jesus Christ and he had been searching for his friend Diane (his sister’s friend) for the past 2000 years. He also reported that for months prior to the instant offense his mother was becoming “devilish with a wry smile and same facial gestures in winking of her eyes as the devil.” He was started on Risperidone, an antipsychotic medication, and there was appreciable change in his psychosis and his behavior. He became calmer, compliant and more cooperative. He was transferred to ECHC on 3/23/03.

He continued to receive treatment at ECHC and was being treated with Risperidone, 6 mg. per day. After the finding of Not Responsible by Reason of Mental Disease or Defect, he was transferred to RRFU on 8/8/03.

Mr. Perkins has been diagnosed to be suffering from Schizophrenia, Paranoid Type, Chronic. He was initially treated with Risperidone up to 6 mg. per day, along with Inderal and Cogentin. Though he showed partial response, he continued to suffer from auditory hallucinations and delusions. In November 2003 Abilify was added. In the beginning it appeared that it may be helpful to him. Mr. Perkins had become more social and more interactive with others. However, as the dose of Abilify was increased to 45 mg. per day, Mr. Perkins’ condition deteriorated. He started exhibiting more evidence of psychosis and became more delusional and his auditory hallucinations intensified. Dr. Deakin finally tapered him off Abilify. Mr. Perkins was recently started on Zyprexa and his dose is gradually being increased. At this early stage in the treatment with Zyprexa, he is showing some evidence of improvement, but it is too early to state how effective Zyprexa would be in resolving his illness.

ALCOHOL AND DRUG ABUSE HISTORY

Mr. Perkins started drinking at age 16. He often drank with friends, mostly on weekends and usually would drink to intoxication. He was arrested for Driving While Ability Impaired (DWAI) in 1994, at age of 20. He underwent court ordered alcohol counseling course. However, he continued to drink throughout his 20’s, mostly on the weekends. In the past he has not received any treatment for his alcohol abuse. He has acknowledged smoking marijuana on few occasions in his life including the day prior to his arrest on 8/14/02. He denied any other street drug abuse.

FAMILY HISTORY

There is no known history of psychiatric illness in the family.

MENTAL STATUS EXAMINATION

Mr. Perkins is a young, Caucasian adult male with a baby face, who looks younger than his age. He was fully alert and understood the nature and purpose of our meeting. He had flat affect and limited emotions during the interview. His psychomotor activity was average. No evidence of abnormal motor movements. His thought process was organized and he answered questions in a relevant and coherent fashion.

Mr. Perkins continues to suffer from numerous delusions and his tendency to misperceive his environment. He continues to believe that he is Jesus Christ. During the interview he said “when I read the Bible, it tells me, there are things directed toward me. Everyone acts as if I was Jesus Christ,” and he went on and on. He also believed that he could communicate directly with God. He continues to misinterpret his surroundings. He reported that while watching “The Price is Right,” he thought his friend Jesse was controlling the contestants on the show. He also believed that his friend Jesse visits him on a flying air board and communicates with him telepathically. Mr. Perkins was quite amazed at his friend’s ability to manage his day-to-day life and still do “these amazing things.”

Mr. Perkins continues to experience auditory hallucinations. He reported that he hears Jesse’s voice telling him “you’ll be okay, what’s up?” He also hears his sister’s voice and he talks with Diane through telepathic waves. His insight into his illness is quite limited. Mr. Perkins still believes that his mother was doing bad things to him. However, he acknowledged that instead of having killed her, he should have left the house.

DIAGNOSIS AND IMPRESSION

Mr. Perkins is a young adult male, who most likely started experiencing early signs and symptoms of Schizophrenia two to three years ago. Unfortunately, his illness was not recognized and he continued to suffer from an illness with insidious onset and gradual course without any proper treatment. He clearly started exhibiting serious signs and symptoms of Schizophrenia about a year and a half to two years ago. Unfortunately, his parents belonged to Church of Scientology and did not seek proper psychiatric treatment for his illness. In fact, during his arrest in August 2003, he was referred for psychiatric treatment, but unfortunately his mother dissuaded his evaluations from providing him with psychiatric care and assured that she would take care of him. He clearly was receiving ineffective treatment from a physician who was treating him based on unproven theories of Schizophrenia.

Mr. Perkins’ instant offense was related to his tendency to misperceive his environment. He started believing that his mother was devilish and started seeing the devil in her eyes. He also started believing in bizarre ideas including the idea that he could communicate with one of his sister’s friends. In fact, his arrest was related to the fact that he went looking for that girl with whom he believed he had developed special relationship and was communicating telepathically.

Mr. Perkins has responded only partially to treatment so far. He responded partially to therapeutic dosage of Risperidone. Dr. Deakin attempted to treat him by adding another antipsychotic medication, Abilify. He initially responded but later his condition deteriorated. Dr. Deakin recently stopped Abilify and started him on Zyprexa. Dr. Deakin informed me that he believes that he is showing some early response to the medication, however, it is too early for one to determine whether or not he will fully respond to this medication.

Mr. Perkins’ condition has not changed significantly since the time of the instant offense. He clearly is less agitated and more amicable. However, his belief system and his perceptions remain quite distorted. He continues to misperceive his environment and suffers from delusions and auditory hallucinations. In my opinion, given the fact that his condition remains pretty much unchanged since the time of instant offense, he continues to pose serious risk of harm to others and potentially to himself. He needs to be observed in a secure and highly structured setting to ensure his and others safety.

PLAN

1. The treatment team will continue to try different medications in order to find the right combination of medications which will help Mr. Perkins recover from signs and symptoms of his illness.
2. Once he has shown good recovery from his illness, the treatment team will institute intensive psychoeducational programs to help him develop appreciation regarding the nature of his illness, its impact on his past behavior, and potentially on his future behavior and dangerousness, and the importance of insuring that his illness remains in remission.
3. Mr. Perkins would also benefit from MICA treatment. He needs to understand that alcohol and substance abuse would complicate his mental illness and could contribute to future dangerousness. We will need to develop a plan for ongoing treatment regarding alcohol and cannabis abuse.
4. Once Mr. Perkins fully recovers from his illness, it is quite likely that he will develop remorse and may potentially become depressed. The treatment team will have to watch him carefully to ensure that he does not develop suicidal tendencies. He will need psychotherapeutic interventions to help him deal with awareness regarding his instant offense.
5. Once patient has recovered from his illness and has developed fair appreciation, he should be given furlough privileges to go outside the forensic hospital so that the team can assess his functioning in less structured settings and during interactions with people outside the hospital.
6. Once the treatment team has determined that he continues to do well on furlough privileges, then the team should recommend his transfer to a non-secure civil psychiatric facility close to his home for gradual rehabilitation into society with close psychiatric monitoring on an outpatient basis.
7. Another important aspect of Mr. Perkins’ treatment would be family counseling/therapy. His family has not spoken with him since the time of his arrest. The treatment team has offered counseling, but they have not responded. It is is safe to assume that they have strong negative feelings toward Mr. Perkins. Such negative feelings on the part of the family would lead to poor prognosis for Mr. Perkins. At some point it would be important that the treatment team help the family understand his illness and its impact on his behavior. Without resolution of strong negative feelings, patient will always be under stress due to family tension and that could lead to relapse of his illness.

RPS/lb

FORM Y
EXAMINATION REPORT
BY QUALIFIED PSYCHIATRIC EXAMINER

(1)    The undersigned is a qualified psychiatric examiner who pursuant to the regulations adopted by the State Commissioner of Mental Health is authorized to conduct an examination of the above-named defendant pursuant to an Examination Order issued by the court on 12/22/03 to determine whether the defendant has a dangerous mental disorder, and if the defendant does not have a dangerous mental disorder, to determine whether the defendant is mentally ill.

(2)    Pursuant to the aforementioned Examination Order, the above named defendant was personally observed and examined by the undersigned on the following date or dates: 1/5/04 and 1/12/04.

(3)    On the basis of facts and information that the undersigned has obtained and on the basis of the observation and examination referred to in paragraph (2) of this report, it is the opinion and clinical judgement of the undersigned that:

X    (a) the above-named defendant has a dangerous mental disorder in that the defendant currently suffers from an affliction with a mental disease or mental condition which is manifested by a disorder or disturbance in behavior, feeling, thinking, or judgement to such an extent that the defendant requires care, treatment and rehabilitation, and that because of such condition the defendant currently constitutes a physical danger to himself or others.

_    (b) the above-named defendant does not have a dangerous mental disorder, as that term is defined
in paragraph (c) of subdivision one of CPL 330.20, but the above-named defendant is mentally ill in that the defendant currently suffers from a mental illness for which care and treatment as a patient, in the in-patient services of a psychiatric facility under the jurisdiction of the State Office of Mental Health, is essential to such defendant’s welfare and that his judgement is so impaired that he is unable to understand the need for such care and treatment.

_    (c) the above-named defendant does not have a dangerous mental disorder, as that term is defined in paragraph (c) of subdivision one of CPL 330.20, and the above-named defendant is not mentally ill, as that term is defined in paragraph (d) of subdivision one of CPL 330.20.

(4)    Annexed hereto and made a part of this examination report is a detailed statement prepared by the undersigned which sets forth the following:

(a)    The diagnosis and prognosis made by the undersigned concerning the defendant’s mental condition; and
(b)    The findings and evaluation made by the undersigned concerning the defendant’s mental condition; and
(c)    Pertinent and significant factors in the defendant’s medical and psychiatric history; and
(d)    The psychiatric signs and symptoms displayed by the defendant; and
(e)    The reasons for the opinion stated by the undersigned in paragraph (3) of this report [including, when defendant has a dangerous mental disorder, an explanation as to why, because of defendant’s mental condition, he currently constitutes a physical danger to himself or others].

Date: January 13, 2004