2.Kimberly Kruse — Direct/Cross/Redirect/Recross

KIMBERLY KRUSE: Good morning. I'm well. Thank you.

KIMBERLY KRUSE: I'm a clinical neuropsychologist. Would you like me to elaborate on my history?

KIMBERLY KRUSE: I was contacted by Dr. Frierson. You saw him testify, I believe it was last week. He asked me to perform a psychological assessment or gather additional information objectively to help him with differential diagnosis and to conceptualize the Defendant.

KIMBERLY KRUSE: Sure. So it's the field -- it's a scientific field of neuroscience with practitioners who develop and use testing to help people understand brain behavior relationships. So not only the psychology or behavioral aspects of how someone functions, but also neuro-cognitively or their thinking abilities.

KIMBERLY KRUSE: So I have a Doctoral Degree in Clinical Psychology with additional training, post-doctoral training in neuropsychology. I'm originally from Florida. I went to University of Central Florida with my undergraduate degrees. I have a Double Major in Psychology and Sociology and then completed my Doctoral Degree in Florida through the American School of Professional Psychology at Argosy University in Tampa. And then I went on to do my residency or internship in Maryland with the John L. Gildner Regional Institute for Children and Families, which is affiliated with Johns Hopkins, which is where more of the medical or neuro-psych side came in.

KIMBERLY KRUSE: I've been the Chief Neuropsychologist and a Hospitalist at Prisma Health for 11 years. I'm also affiliated with Kershaw County Hospital System and Compass Health, which used to be Health South. And so on a day-to-day basis, I'm performing differential diagnosis. I'm using psychological testing instruments, neuropsychological testing instruments to determine if patients meet criteria for psychological or neuro-cognitive disorders and help in terms of planning for prognosis and discharge from the hospital or admission to the hospital.

KIMBERLY KRUSE: Thousands.

KIMBERLY KRUSE: I've been qualified in the South Carolina Judicial System approximately 75 times as an expert in the field of neuropsychology and that would span across civil, criminal and Probate Court matters.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: I've worked with Dr. Frierson for a few years now. My role would be to assist in guiding his clinical opinion by providing objective data. So, clearly, he did, I don't know, even know how many hours of research going through history, various forms of history. But he would -- encounter to, I think, or just to compliment or look at psychological testing data, he did have that as part of his review and it didn't seem to make sense to him. And so, from my perspective, my role was to perform similar evaluations to look at how the Defendant measured up in terms of intellectual ability, cognitive and behavioral functioning.

KIMBERLY KRUSE: I did.

KIMBERLY KRUSE: February 22nd, 2019. It was a Friday.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: He did.

KIMBERLY KRUSE: He did.

KIMBERLY KRUSE: I did.

KIMBERLY KRUSE: So Mr. Jones has a complex history. We all have seen the head scans of the structural right frontal depression in his skull. So I did cognitive testing to look to see if he met criteria for a neuro-cognitive disorder or if he had any residual or leftover impact from that that would impact his ability to think clearly and make decisions. I also did a psychological profile, which is, essentially, gathering data or information on behavior and how someone functions, personality aspects. That would be the psychological piece. And then, of course, we needed test for the psychosis piece which was reported, and so I also did that.

KIMBERLY KRUSE: Yes.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: That's a fine term to call it. So before we assess anyone, we need to know if -- because this is objective data, I need to understand how to apply it. Is this someone who is giving appropriate effort? Because if not, if I say this person is in the second percentile or so, was it because they didn't apply the effort or was it because they couldn't apply the effort in terms of their neurochemistry or what's going on in their brain. So these tests are somewhat of a screen to see if the data is going to be valid that you collect. Because if you collect data and you use it and you stand behind it, you want to say that it is valid. And so I did that not only with the cognitive testing, but also with the other aspects of testing I did.

KIMBERLY KRUSE: So I'll reference my report which I have here. So in terms of effort testing, specifically for cognitive functioning, I administered three tests. I relied upon four.

KIMBERLY KRUSE: Something called the Dot Counting Test, the Rey 15 Item Memory Test and the Rey 15 Item Recognition Trial.

KIMBERLY KRUSE: Sure. So the Dot Counting Test, it has something we would say has a high face validity. So it's -- it really is just what it says. It's a piece of paper with dots. And we ask the patient to count the dots as quickly as possible. Now, these dots get more complex as you flip through the test. Yet, they're grouped in ways that we are used to seeing, like, if you saw five dots and they were like they would be on a dice or on a set, you would know. You wouldn't have to necessarily count them because you're visually recognizing those. So they get more complex in terms of how they look, but really you should be to kind of scan through them quickly. And Mr. Jones did just fine with that.

KIMBERLY KRUSE: And I'll be brief on my summary of these. I mean, I could go on and on. But the Rey 15 Item Memory Test, we present a stimulus sheet with 15 items and there it would say one, two, three, A, B, C and so forth. And it's something, again, it looks like a lot of items, but really you can use mental heuristics or shortcuts to remember those. And then after ten seconds, we ask if the patient can remember what they saw. And again, he performed within normal range on that.

KIMBERLY KRUSE: Recognition is now tell me -- I take away the stimulus card and say what do you remember. And he did just fine with that as well.

KIMBERLY KRUSE: That was a test I reviewed by Dr. Brawley, the test of memory and malingering. It's something I would have given had she not given it. It's a standard test to administer prior to cognitive testing. And again, that was within normal range.

KIMBERLY KRUSE: No.

KIMBERLY KRUSE: Correct. Now, she has worked with Dr. Frierson in the past.

KIMBERLY KRUSE: For this case, she was not associated.

KIMBERLY KRUSE: That's my understanding.

KIMBERLY KRUSE: I did.

KIMBERLY KRUSE: Yes. It is considered the best practice to give a variety of tests. No one, depending on what field you're in or what area you're testing, psychologically or neuro-cognitively, should you ever give one or even two tests and make an assumption from that.

KIMBERLY KRUSE: Yes, up there, yeah, now it does.

KIMBERLY KRUSE: So the way I explain this to my residents, I -- this is a noninvasive way of seeing how someone's brain works. So it's almost in a way looking at -- it's not like a functional MRI, but I use that example because when you have someone under a brain scan and you give -- introduce different thoughts to them, you can see how their brain works. And so psychological testing in terms of the neuro-cognitive performance, it mimics that. So each of these tests are meant to see how someone is functioning or their ability to attend to information, to remember information, not just right then, but also a delayed memory recall. Visual spacial functioning, so how well are you able to perceive items, remember them, manipulate them in your mind from a visual spacial perspective. And it's something that you -- I think you all have heard of throughout this trial, executive functioning, which is just like what it sounds, it's like having -- it's the executive of your brain, the person who -- or the tendency for your brain to execute attention, concentration, make decisions, reasoning abilities. So these tests, the reason why there's so many different ones, and even within the tests, there's different subtest, is to ensure that we're measuring all of these areas.

KIMBERLY KRUSE: I have.

KIMBERLY KRUSE: It was. It meets criteria for traumatic brain injury, of course. I mean, he has a structural -- and as people have pointed out -- or experts have pointed out, you can see the skull depression. But a brain injury does not equate to neuro-cognitive disorder. If it was that straightforward, my job probably wouldn't exist. So, certainly, it is impressive in viewing and I think the term in itself, traumatic brain injury, is very scary to people. A lot of times, we have something called neuro-plasticity, the brain kind of regenerates in areas it's been injured. And we are still -- there's so much research to be done about how the brain operates, of course. But at this time, there is the understanding that, you know, impacts the brain can occur and some people are on the negative side of that and some people come out and can function back at their baseline.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: I, actually, had the opportunity to dissect a brain this summer and I will tell you, the trauma I saw in some of these brains and the reports on how -- of course, this was postmortem, so I didn't get to assess these people, but the functional aspects of how they were performing in life, it was quite drastic.

KIMBERLY KRUSE: I do.

KIMBERLY KRUSE: Yes, I see thousands of veterans with co-morbid or -- occurring at the same time diagnoses of mental illness and also having some type of traumatic brain injury. And it's one of the things I do for compensation and pension purposes through the VA to assess them and determine if they meet criteria for a neuro-cognitive disorder or psychiatric disorder.

KIMBERLY KRUSE: He performed very well. In comparison to Dr. Brawley's performance where she had him assessed as being in the first percentile, in, at least, three of the areas I saw, we went from the first percentile back in '16 when she saw him, in my testing, he was in the 79th and 80th percentile.

KIMBERLY KRUSE: If you have a hundred people, 99 of those people would do better than you. You would be at the very bottom of the performance ability.

KIMBERLY KRUSE: In the 80's, I believe.

KIMBERLY KRUSE: Lower than certainly his functional abilities would suggest.

KIMBERLY KRUSE: I think that was one of the primary things that stuck out to him, yes.

KIMBERLY KRUSE: Yes, that was of concern to him. When you conceptualize a patient, like I had said before, you never take one piece of information and make all of your assumptions on that. And particular in Dr. Frierson's role in this case was to look at everything. And when he looked at that assessment and the first percentile ranges and what we know for patients functioning in the first percentile ranges, they're not -- you know, a lot of them aren't able to even drive a car. So this didn't make sense to him and I think that was the primary reason he asked me to perform my evaluation.

KIMBERLY KRUSE: Yes, I mean, there's a variety of scores obtained, but the 80th percentile is very good.

KIMBERLY KRUSE: So overall, he did not meet criteria for a neuro-cognitive disorder based on this evaluation.

KIMBERLY KRUSE: Yes.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: He told me that.

KIMBERLY KRUSE: Mr. Jones. He had expressed that to me and had mentioned that he felt very much slowed in his psychomotor behavior, meaning just your ability to kind of move around and function in general, very slowed and, also, that it was infecting -- impacting the way that he was thinking in terms of processing speed, in particular, which is one of the main areas that were at deficit in Dr. Brawley's report.

KIMBERLY KRUSE: That is my conclusion, absolutely.

KIMBERLY KRUSE: Yeah. We would not see a head injury in the first percentile or neuro-cognitive disorder of such, exclusive from a state of delirium that then jumps into the 80th percentile just -- of any organic reason. There's no research supporting that that I know of or that any of my colleagues --

KIMBERLY KRUSE: No.

KIMBERLY KRUSE: That's the biggest explanation I can come -- the best explanation I can come up with.

KIMBERLY KRUSE: It is. So I'm not a medical doctor, however, it is my job to understand how my patients are presenting, hence, why I give effort and validity testing and why I have to also understand that day, have you taken anything before this test that will impact your performance. Patients regularly prescribed Xanax, for example, I ask them to withhold that medicine before they come in for testing because, certainly, that would impact their performance. So the information or data I'm collecting must be a valid representation of their true baseline ability. It cannot be their functioning influenced by a substance, prescribed or other drug. And if they've had a good night's sleep sometimes. I need to know they're able to give the appropriate effort.

KIMBERLY KRUSE: Correct. And that is one of the requirements for a diagnosis of neuro-cognitive disorder.

KIMBERLY KRUSE: I did not diagnose him with a neuro-cognitive disorder, no.

KIMBERLY KRUSE: Then we can get into the report of symptoms regarding psychosis and look in that area. I also performed a series of tests looking at symptom validity. So they all fall under the same category of validity testing, whether you call it effort or performance or symptom validity. I mean, if we got down into the definitions, we could get a little more detailed, but I don't think there's a need for that to help you understand how I used these tests. That is similar, but, of course, in this area, I'm looking to see if I can have valid information collected based on his self report. And these tests are meant to look at the range of symptoms reported by individuals with schizophrenia or psychosis and then it compares the patient's performance to that. So it helps us see if the person is able or is willing to give a straightforward account of symptoms and if those are consistent with known psychiatric populations.

KIMBERLY KRUSE: If it -- right, if it falls within a range that would be clinically relevant.

KIMBERLY KRUSE: No. I would definitely want to know that. As far as I -- all the history I've done through, I'm the only one that has done any personality assessment or any testing of psychosis, any validity of how he's reporting symptoms, any testing to rule out malingering, rule in malingering. I don't see that anywhere else.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: Correct. And Dr. Frierson did not dictate the testing battery I gave.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: I did.

KIMBERLY KRUSE: Yes.

KIMBERLY KRUSE: Yep. And again, I'll summarize and be brief. So the SIMS test is -- and I think Dr. Dorney testified to this. She had said that that was a test that if someone scores high in an area, then it does indicate the need for further testing. It's a structured interview for malingered symptomology. And so it has a series of questions that look to gauge a patient's response in comparison to individuals with known psychiatric disorders that are validated. And so it helps us to see if the person is overreporting symptoms and also if they're underreporting symptoms. And in this area, Mr. Jones had performed within normal ranges in all of the areas except for the area of psychosis, which was a score of six. And just to make this very explicit, I actually copied out of the manual the sentence that goes with the score he obtained. So his score was six. The manual says anything over a one is clinically significant. And this is what it says, Even low levels of endorsement of such inconsistent, bizarre and/or atypical symptoms is highly suggestive of malingered psychosis, even in the rarity and with which such symptoms are endorsed by actual psychiatric patients. So to break that down, if you were to know someone, a friend or someone with schizophrenia and they were to explain to you what it's like to have schizophrenia, that would be a baseline, let's say, of schizophrenia, but this level of endorsement would have been significantly more elevated than that.

KIMBERLY KRUSE: These are symptoms that are inconsistent with schizophrenia, yet, meant to mimic those of schizophrenia.

KIMBERLY KRUSE: Based on his self-report, it's suggesting it's not reliable.

KIMBERLY KRUSE: So again, we're seeing the same theme in this area. This test also breaks down the patient's reported symptoms into different areas. This is purely really looking for psychosis. And the areas reported by Mr. Jones to be in the clinically significant range were found to be -- let's see, just make sure I'm seeing this clearly. Rare symptoms, so symptoms -- I mean, that's pretty self-explanatory, that are rare within psychosis. So symptoms not typically endorsed by individuals with schizophrenia or other psychotic disorders. Symptom combinations, that was another one that was in a clinically relevant range, so it takes that, may be experienced by patients with known psychiatric disorders and then it puts them together. Like when I hear voices I lose a lot of weight. That's not a specific example, but it's two things that might be reported, but are usually not reported together. And then, also, this is the category, and probable and absurd symptoms. That was the highest rate of responding. And the test found that to be in the definite range of malingered symptomology. And the other two I just mentioned were in the probable range.

KIMBERLY KRUSE: Two that are probable and one that is definite per this test.

KIMBERLY KRUSE: That test also yielded a significant score for the likelihood of malingering. He had -- the highest score was in unusual hallucinations, so the report of hallucinatory experiences, so the visual or auditory symptoms. And in this case, it looks at all kinds of symptoms. Any sensory experience you can have, could be -- some people have tactile hallucinations, that's very rare, olfactory hallucinations where you smell things that are not there, gustatory hallucinations. It goes down all the senses especially, but in this test, in particular, his score was significant in unusual hallucinations. Extreme symptomology, so his report of symptoms was beyond that that individuals with schizophrenia would typically respond to. And also and unusual symptom course. So if you look at symptoms over the course of time, his report of symptoms did not match up with those individuals with known psychotic disorders.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: Eight hours.

KIMBERLY KRUSE: We did.

KIMBERLY KRUSE: I did.

KIMBERLY KRUSE: He did. He explained that the visual permutations, you've heard that word in this trial, or the visual -- atypical visual experiences he was having, he described it like the movie Dumbo, like the pink elephants on parade. There's a part of that movie that has a very odd visual piece to it. And I did look it up because I remember watching the movie as a child, but I didn't remember that part. And it's -- it's an odd video. I mean, it's an odd part of the movie.

KIMBERLY KRUSE: No.

KIMBERLY KRUSE: Yes, A Beautiful Mind.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: That was his comparison.

KIMBERLY KRUSE: My testing data did not suggest such.

KIMBERLY KRUSE: I think it would be very apparent if someone was in a full psychotic episode and, certainly, no testing data, if you were trying to look at baseline behavior or cognitive functioning, would be valid in that regard. These tests, particular the ones to rule in or out malingering, are normed in populations. So these are not tests that I came up with, these are not tests that you research on line that you can find and take yourself. These are copyright materials. These tests are based in psychometrics neuroscience. They are normed across populations, thousands of individuals, to look at what is a normal base rate of behavior and it compares the patient's performance to such, to help the doctor if this person can give appropriate effort. And so these are scientifically peer reviewed testing measures. To make a comment like that suggest someone is not competent in psychometrics and is also -- it just explains that maybe someone who makes that comment doesn't really understand how the tests are used or how they're developed.

KIMBERLY KRUSE: Part of the reason why I do what I do and I feel comfortable on the stand is because it's not -- I'm representing the data here. The data speaks for itself. And so, yes, that is correct. The way this information is collected is standardized and the way it's scored is standardized, so it really takes out -- I wish I could say I'm this brilliant person coming up with all of this, but it's the tests. So the test itself gives us the information.

KIMBERLY KRUSE: Correct, that would be the appropriate word.

KIMBERLY KRUSE: I believe he derives his opinion based on collecting information and history and looking for patterns.

KIMBERLY KRUSE: Yes, that's extremely common. Because you all have seen, there's research studies and articles that speak to such, that, you know, subjectivity and clinical interviews, at times, can be up to a rate of about 50 percent error rate because of the subjectivity involved. And I think that's one strength of my field, that we're able to provide objective testing data to help support or not support diagnoses.

KIMBERLY KRUSE: I believe so.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: So in layman's terms, personality testing. So testing of behavior and helping me understand how he thinks, what his attitudes are in life, how he approaches problems.

KIMBERLY KRUSE: Yes.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: So these tests, again, personality measures. They also look at what we -- in the past Diagnostic and Statistical Manual refer to as Axis I disorders or depression, anxiety, that type of thing. But, generally, these tests are helpful in understanding how people go about life and what they might be like in terms of personality and how they might cope with problems or stressors. The next thing, too, about these tests is they have built-in validity scales themselves. So you wouldn't have to administer like I did with the psychotic testing or with the cognitive testing symptom validity tests prior to this. They, themselves, tell you how the patient approaches the test and how they responded. They pick up on patterns.

KIMBERLY KRUSE: Sure. So on the MMPI-2, which is -- I think in our country and also in Canada, the number one used test in forensic settings to gather information. Highly respected in my field, highly valid, highly reliable test. He scored a 65 on the L scale -- oh, I'm sorry, he scored a 74 on the L scale with a -- and the cutoff score for that is 65. So what is that telling me? He scored beyond the range of what we would want to see in terms of looking at someone as a reliable historian, if they're able to provide information in the way that would be similar to their true baseline. So within that test, I had to take that into account.

KIMBERLY KRUSE: The lie scale.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: Well, I was just going to report on what he had reported. Now, this is one where it's true/false questions, a lot of true/false questions. And so you go through and you say true or false to questions. And those questions -- we're not going to get into the specifics of the questions. Those are actually -- you don't ever look at the specifics of the questions even though I know that's been done, not in this case. But the way he reported the symptoms revealed his report of persecutory ideas, self-consciousness, social discomfort, emotional alienation.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: Yes. Schizo-typal characteristics. I mean, that was how he was responding to the tests. Those were the areas that came up.

KIMBERLY KRUSE: So, again, looking at the validity scale built within the test, I found a high degree of self-revealing inclinations, so overreporting of symptoms in that regard. And within that scale, again, similar findings. Anxiety was highly elevated. He hit on a number of personality traits across almost all personality -- that we would say found within personality disorders. So it was somewhat difficult to interpret because you normally don't have someone with say, who is significantly withdrawn, but also an extrovert. It was just difficult to interpret because of the disbursed symptom report.

KIMBERLY KRUSE: That would probably be an easier way to say that. Thank you.

KIMBERLY KRUSE: Correct. And, certainly, we all have different aspects of our personality. Maybe in some situations, you might feel more comfortable to be outgoing, so it was not -- the test was not completely invalid, it just helped me understand how he sees himself and so that there may be some -- I'll use your word, like kind of a hodgepodge of personality traits or characteristics that are at play in everyday life with him as he experiences the world.

KIMBERLY KRUSE: So this one was interesting to me. So, again, back to the validity scale, which is the first thing I look at before I interpret any data as you can see across any domain I do of testing. In this case, not only was overreporting found, but underreporting was found. And in the area of underreporting, it would be that he would not admit to things that most people will admit to, that when people are not -- don't want to quickly get up and say that they do, that they probably might do. So a good example of that would be have you ever left the bathroom before washing your hands? It's not the first thing you might want to tell people that you've ever done in your life when you meet them. Have you stolen a cookie from your grandmother's cookie jar. You know, things like that that you might not want to admit to. Well, his defensiveness in that regard was very high. So there was an underreporting of symptoms in that regard. Yet, an overreporting of symptoms in the area again of psychosis or in that area where you might have difficulty with what we call reality testing.

KIMBERLY KRUSE: I think it's -- so these tests are not for malingering, but these tests do represent a pattern of behavior similar to that found in the earlier testing we discussed of a tendency to overreport symptoms, a tendency to maybe underreport shortcomings that are even normal shortcomings that we all have. And I think the most important piece to all of it is can we look at this person as a credible historian? And so based on this testing, this is saying no.

KIMBERLY KRUSE: Yes.

KIMBERLY KRUSE: So, overall, criteria is not met for a neuro-cognitive disorder. So while we do have history of TBI, there are no findings on my neuro-cognitive assessment to suggest that cognitive impairment impacts daily functioning or that even within the frontal lobe functioning that this is a person who would have difficulty reasoning, engaging in judgment, planning, executing multi-step behaviors. I didn't see anything there to represent a deficit. Beyond that, there were some atypical personality findings, as I discussed. Once I kind of looked at all of the data together, I think that the thing that stuck out to me most was more of an anti-social and borderline personality.

KIMBERLY KRUSE: It's someone sees the world very much in black and white, someone who has a significant fear of rejection, abandonment, disapproval, they're very quick to react to even perceived slights from an interpersonal perspective. These are people that have mood swings very easily throughout the day. And those are based on external triggers, usually, those that are interpersonal. And it's usually prompted by any sense of rejection or abandonment. Borderline personality historically and per data does have a strong pattern of individuals who engage in self-mutilation or cutting behavior on themselves. I know that that was mentioned in the history, yet, I believe Mr. Jones denies ever doing that.

KIMBERLY KRUSE: No.

KIMBERLY KRUSE: Correct. He did not meet criteria for any specific diag -- disorder, I should say, yet, there is a diagnosis of unspecified personality disorder. And that's kind of like what you had mentioned with the hodgepodge of symptoms. So when we have clinically significant symptoms in multiple areas across different disorders, yet, all the criteria are not met for such disorder, we come up with unspecified, which means yes, there's something there, but all of the criteria are not met.

KIMBERLY KRUSE: Someone who has a tendency to not observe regular -- regulations of society, laws, lack of empathy for others, more inward focused than outward focused in terms of self versus others.

KIMBERLY KRUSE: Yes.

KIMBERLY KRUSE: So in our society, those two are commonly interchanged, yet, they are very much different clinically. Even people I know oh, he's so bipolar. You know, people often use that term to say oh, you know, any little thing will set someone off. That is not bipolar disorder. Bipolar disorder occurs when there's an enate or organic process going on. It's not driven by interpersonal stressors. The borderline process is. It's the person who in the same day might look different in regard to mood. And their ability to regulate emotions in the face of interpersonal stressors is extremely poor. They might have episodes of rage. Whereas, bipolar disorder, you would see mania, disorganized behavior, someone who it looks almost a different person and that would last for several days to weeks. And that's also accompanied by severe depressive episodes.

KIMBERLY KRUSE: There is a book written and it's since been revised and that's exactly the title, I Hate You, Don't Leave Me. And oftentimes, when I've had borderline patients and they know about that book, they'll say, you know, my relationships are like I Hate You, Don't Leave Me. It's this turmoil of -- you know, this fear of rejection and abandonment, but, also, just the difficulties within the relationship and lots of fighting against each other. Yet, the makeup period kind of meets all the needs that the person wants because it's the opposite of the fear of rejection and abandonment. So it's almost like they create that in their lives at times, significant turmoil. But yes, that is a book written by, I believe psychiatrists working with patients with borderline personality disorder and their experiences of such.

KIMBERLY KRUSE: No.

KIMBERLY KRUSE: It's a pattern of maladaptive behavior over the course of time that is typically seen in the way the person interacts with people and interpersonal functioning. So it's something that over time, it's usually developed, a lot of them, in difficult childhood experiences. I mean, in this case, if we're finding that the borderline personality traits is being strong, it makes sense that there is likely some sense of rejection or abandonment earlier in life that fits in terms of the clinical conceptualization.

KIMBERLY KRUSE: There can be dissociative periods in borderline personality disorder, but in that regard, the person would meet full criteria and that is not the same as hallucinogenic psychosis.

KIMBERLY KRUSE: Not per my testing or the history I've reviewed, no.

KIMBERLY KRUSE: No.

KIMBERLY KRUSE: No.

KIMBERLY KRUSE: Correct. Outside of possible substance-induced psychosis.

KIMBERLY KRUSE: It means the person took the drug voluntarily, yes.

KIMBERLY KRUSE: Correct. In looking at the history, you wouldn't have schizophrenia occurring over the course of 24 hours, you know, at a one-hundred percent rate and then the next day, not have it outside of an intramuscular injection of -- I mean, that's not a typical course of psychosis, no.

KIMBERLY KRUSE: I'm sorry, I couldn't hear you.

KIMBERLY KRUSE: I am not an attorney or a lawyer.

KIMBERLY KRUSE: I don't know what is and what is not a defense.

KIMBERLY KRUSE: It's not found in my testing and I don't know how to test for that exactly.

KIMBERLY KRUSE: Thank you.

KIMBERLY KRUSE: Of course.

KIMBERLY KRUSE: Good morning.

KIMBERLY KRUSE: That's incorrect.

KIMBERLY KRUSE: We did.

KIMBERLY KRUSE: So I did a diagnostic conceptualization at the end. I did not specific -- well, I discussed malingering in terms of the behavior. In terms of the cognitive aspect of his functioning, he did not attempt to present himself in a negative way. So I'm very careful about the way I write things on my reports so in other cases where I might list out diagnoses, if I'm the sole evaluator. In this case, I was providing assistance to Dr. Frierson with my data. So he was the one that formulated the diagnoses. So when you and I had spoken, I said -- I mean, not only did I not list anything in a line like we do with diagnoses, I mean, I didn't list personality disorder, I didn't list substance-induced psychosis, but I did describe everything in a paragraph.

KIMBERLY KRUSE: Does that clarify your question?

KIMBERLY KRUSE: I understand.

KIMBERLY KRUSE: No.

KIMBERLY KRUSE: Yes, I think I have the summary of her report, correct.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: She said that was a factor, but not entirely due to his medication was his IQ suppressed.

KIMBERLY KRUSE: Yes, correct.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: Neuro-plasticity.

KIMBERLY KRUSE: So succinct or successive concussions or brain injuries are known to have exacerbatory impact, yes, in terms of --

KIMBERLY KRUSE: Yes. You're less likely to recover as well as you did the first time.

KIMBERLY KRUSE: I am.

KIMBERLY KRUSE: Yep. So that's an example we commonly use in teaching the residents or any type of student of someone who had trauma, significant trauma. I believe it's a railroad bar went through the frontal lobe and out of his head, actually. He did survive the accident, but his personality changed drastically.

KIMBERLY KRUSE: The pictures -- we use the word impressive. I mean, it was a very -- it wasn't -- it was very large, correct.

KIMBERLY KRUSE: Yeah, and out through the other end of his skull.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: I don't remember the history of it, but yeah, it was a while ago.

KIMBERLY KRUSE: Yes.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: I don't -- I don't remember the exact details, but, right, he was able to perform his job. I remember that.

KIMBERLY KRUSE: The teachings of the case are in regard to personality.

KIMBERLY KRUSE: Drastic change difference in personality for this case in particular you're speaking about.

KIMBERLY KRUSE: I don't know -- put together is not a term I can use in terms of data. I don't know about any data discrepancies with him. I don't know about any IQ testing that was performed.

KIMBERLY KRUSE: But what you're saying in general is correct. He was able to return back to his work.

KIMBERLY KRUSE: And the main teaching of the case was that the main symptom that was observed was the personality change in this individual because of that injury.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: In the personality ones --

KIMBERLY KRUSE: -- right, some of them, correct.

KIMBERLY KRUSE: In some of the tests, correct.

KIMBERLY KRUSE: There are some personality tests that are entirely different than the ones I administered. You're correct, these were -- right, paper and pencil, true/false-type questions.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: In the three personality tests I administered, yes, those were scored in that manner.

KIMBERLY KRUSE: No.

KIMBERLY KRUSE: So in some cases, you can have reports generated that do some degree of interpretation. Other times, you can just have the profiles, which that's the part that I rely on. In this case, I believe one of them came with some type of interpretation. But that's the computer that's kind of spitting what it would for anyone scoring in those areas --

KIMBERLY KRUSE: -- but the other two, specifically, the MMPI and MCMI, I utilized the T scores or standardized scores. I can show you, but it's a -- it's a -- kind of peaks and valleys. It's look like if you have an EKG, what you would see go across the screen, that's how I interpret the data. So I don't rely on the computer because it's not a doctor.

KIMBERLY KRUSE: Right.

KIMBERLY KRUSE: I don't read whatever the computer -- I think it automatically prints it out. I mean, that's not what -- I'm actually using the data sets and I extrapolate my opinion based on if something meets a threshold or exceeds a threshold of clinical significance in terms of the T score generated.

KIMBERLY KRUSE: I think -- you know, it's helpful for graduate students or people who -- you know, psychometrist, maybe, to gain a better understanding of the tests. But you would never interpret a patient or conceptualize a patient based on what a computer is saying.

KIMBERLY KRUSE: Right.

KIMBERLY KRUSE: If I did, then I did, yes. I try to send everything I had to you all.

KIMBERLY KRUSE: If it's something relevant to the diagnosis, yes, there are certain ways we say things that are very stereotypical, if you will.

KIMBERLY KRUSE: I have a copy.

KIMBERLY KRUSE: Yes.

KIMBERLY KRUSE: I do.

KIMBERLY KRUSE: If they were things I thought were relevant that met my interpretation, that is what I would use, yes.

KIMBERLY KRUSE: Not substantiated what I thought, but were relevant to the conceptualization or what I gathered from the instrument.

KIMBERLY KRUSE: So are you inferring I'm taking pieces of the report to meet my --

KIMBERLY KRUSE: I'm not sure what --

KIMBERLY KRUSE: Well, any of the computer part would be. I mean, anything -- anything that is being extrapolated from the data, it will summarize.

KIMBERLY KRUSE: Right.

KIMBERLY KRUSE: Right.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: I would definitely characterize it as that. So someone who has a negative view of themselves or -- there can be multiple reasons for negative impression management. I wouldn't say malingering.

KIMBERLY KRUSE: Correct, it is part of the validity scales that helps us understand the method by which the patient responded.

KIMBERLY KRUSE: If that's from what I had given you, the computer -- right, so the computer picks up on different methods of responding. I believe, also, it might have said the same thing about positive impression management. So, again, it's interpreting scale by scale.

KIMBERLY KRUSE: But if it was in what I gave you, then it's what -- it's from me.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: Sure.

KIMBERLY KRUSE: Again, if it's there and that's what the computer -- and I wouldn't be surprised because it's absolutely how he was reporting symptoms.

KIMBERLY KRUSE: I confirm anything that I gave you as being part of the report.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: Based on this measure, yes. And rarely do we use what the computer is printing out as -- I mean, we may or may not go with any of those diagnoses. But yes, you're absolutely right, based on the data that was put in for that particular assessment, correct.

KIMBERLY KRUSE: I believe in psychometric properties, so -- and I think I know where you're going. So in terms of the method of responding, I think the validity indicators, which, like you said, there was one piece of the report that said negative impression management was not found, but there's also another part of the report that might contradict that within it.

KIMBERLY KRUSE: Uh-huh.

KIMBERLY KRUSE: In particular areas, uh-huh.

KIMBERLY KRUSE: Yeah, I'm sure it did. That's how he was responding. Yes.

KIMBERLY KRUSE: Yeah. I don't know if I have the interpreted -- did I give you a report for this case?

KIMBERLY KRUSE: Okay.

KIMBERLY KRUSE: Yeah.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: The validity of the testing. So there's built-in validity scales. And, specifically, for the MMPI-2, it can do a corrected scoring based on the patient's response pattern. So in this case, we did have a tendency of overreporting symptoms, so sometimes it will correct it to some degree. There's different scales used. The MMPI has become increasingly complex with additional scoring criteria and methods at which this computer -- I mean, when I learned it, we did paper and pencil scoring. Everything we had to do, we did on our own and so -- I mean, as the years have gone by, they've developed all these different criteria for scoring. So when I -- I did the most basic type of printout of data interpretation in this one and utilized that. And, of course, that makes sense scientifically in terms of what's been backed and supported for the most years versus some of these new scoring techniques.

KIMBERLY KRUSE: No, my report would be thousands of pages if I did that.

KIMBERLY KRUSE: Oh, I -- I'm sorry, I misheard you.

KIMBERLY KRUSE: Yes, we did.

KIMBERLY KRUSE: You told me you found the SIMS in German and translated it after spending several hours doing so and you took it and had a significant score.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: So I would be surprised if that didn't exist in the computer-generated report. Not only for that, but I bet on the MCMI, I bet you have another one that also says the same thing --

KIMBERLY KRUSE: -- as you do with the PAI because this data is all consistent across the board. So it's actually helpful that you're pointing that out. As we said before, the validity testing I did shows he has a tendency to -- a goal directed tendency to report symptoms of psychosis beyond those experienced by populations with found psychiatric disorders. So in self-report measures such as these three tests that I gave, I would expect him to be reporting those symptoms. You're reading a computer-generated report that says okay, so this person responded to three, 12, 17 and so and so, so this is what we find from that in terms of that person's response style. So as the doctor, I have to make sense of all this information. So when I find that in that area in particular he is not a valid historian, I cannot put that into my report because that is not accurate data that I can support based on my testing. Now, we're not seeing overreporting in the areas of other disorders. We're seeing overreporting in areas or reporting of such in this one area that you're continuously pointing out. And that's the area that I found him to be an unreliable historian in. So if my testing did not have that, I would have to explain that process. I would have to -- I probably wouldn't have made such a big deal of the validity testing in the beginning because it would contradict itself. So this actually supports the testing I had done before this.

KIMBERLY KRUSE: Right, you're just saying what the computer is saying.

KIMBERLY KRUSE: I just want to make sure psychometrically that the jury is understanding of where that information comes from.

KIMBERLY KRUSE: Okay.

KIMBERLY KRUSE: Right, based on the Defendant's self-report, yes.

KIMBERLY KRUSE: That's what it's used for, to gauge effort responding, uh-huh.

KIMBERLY KRUSE: Correct, to see the effort they're able to put in, to see if they're overreporting symptoms.

KIMBERLY KRUSE: Correct. That test, in particular, looks beyond psychosis, so that's one we would give for patients that we might want to ensure are not overreporting cognitive symptoms as well. So in traumatic brain injury cases, I might give that test where there's no report of psychosis because that test also has elements of intellectual ability and other properties that someone might overreport or underreport on.

KIMBERLY KRUSE: Correct. So for each subscale and also a total score.

KIMBERLY KRUSE: Correct. He scored below that for a total.

KIMBERLY KRUSE: Uh-huh.

KIMBERLY KRUSE: Yes. My apologies.

KIMBERLY KRUSE: Correct, he performed within normal limits.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: Correct.

KIMBERLY KRUSE: SIRS, that's fine.

KIMBERLY KRUSE: Right. Two that fell in the probable range and one in the definite range.