Full opinion text
FINDINGS OF FACT AND CONCLUSIONS OF LAW WOODCOCK, District Judge. In 1980, Cosme Sanchez Ramirez, then a teenager, was forced to leave Cuba for the United States at the point of a bayonet. A true stranger in a strange land, Mr. Ramirez has led an unfortunate and chaotic life in the United States. On April 13, 2005, by this time a felon, he found his way to Bangor, Maine, where he entered a pawn shop and tried to buy a High Point .380 pistol. Following indictment on federal gun charges, he proceeded to a bench trial, asserting an insanity defense. The Court concludes that the Government has proven each of the elements of each count beyond a reasonable doubt and that Mr. Ramirez has not sustained his burden of proof on the insanity defense. The Court finds him guilty as charged. I. STATEMENT OF FACTS On September 13, 2005, a federal grand jury indicted Mr. Ramirez, alleging violations of 18 U.S.C. § 922(g)(1) (felon in possession), 18 U.S.C. § 922(a)(6) (false statements in connection with the acquisition of a firearm), and 18 U.S.C. § 911 (false representation of U.S. citizenship). The parties presented evidence over a five day period in January 2007, filed subsequent memoranda, and made final arguments on June 11, 2007. A. The Government’s Case-in-Chief 1. Frati the Pawnbrokers On April 13, 2005, Mr. Ramirez entered Frati the Pawnbrokers (Frati), a federally licensed firearms dealer, in Bangor, Maine, and expressed an interest in purchasing a gun. He completed ATF Form 4473 and returned the form to Mr. Frati; he also provided a Social Security card as identification, which Mr. Frati photocopied and retained with Form 4473. While inside, Mr. Ramirez handled two guns: a Jimenez Arms 9 millimeter and a High Point .380 pistol. Of the two guns, Mr. Ramirez expressed a preference for the High Point .380 pistol because it was smaller. Mr. Frati testified that Mr. Ramirez had made statements to the effect that guns “are supposed to be small so you can hide them in your clothes or put them in your pocket,” so that “if a person walked near you or a police officer came in contact with you he wouldn’t be aroused or think that you are armed in any way.” Tr. II at 30:9-11 (Docket # 185). Another patron in Fra-ti’s testified that he heard Mr. Ramirez say that he “wanted to be able to hide a weapon on him so that no one would know ... [so that] he could get the man before the man got him.” Tr. II at 57:12-15. Finally, a cabdriver testified that Mr. Ramirez told him he wanted to get a gun for protection. After Mr. Ramirez left the store, promising to return with proper photo identification, Mr. Frati submitted Form 4473 to the National Instant Check System (NICS). Among other information, Mr. Ramirez wrote “No” in response to a question asking whether he had been convicted in any court of a felony; he provided Miami, Florida as his place of birth, and he wrote that his country of citizenship was the United States. During the phone call, NICS initially responded “delayed,” but then denied approval. On cross-examination, Mr. Frati acknowledged that when Mr. Ramirez first returned Form 4473, he had neglected to answer question 10, which asks “What is your country of citizenship?” Gov’t Ex. 3. Mr. Frati pointed this out to Mr. Ramirez who inserted “Yes, USA.” into the blank space. In addition, Mr. Frati helped Mr. Ramirez to spell “Penobscot” County. Other than that assistance, Mr. Frati testified that Mr. Ramirez completed the form entirely on his own. Mr. Ramirez also marked that he was “American Indian or Alaska Native.” Gov’t Ex. 3. 2. The Bureau of Alcohol, Tobacco, Firearms & Explosives Agent Erik Tall, of the ATF, obtained the original Form 4473 completed by Mr. Ramirez and the photocopy of the Social Security card. Agent Tall completed an Interstate Identification Index check, which is a national database that keeps track of criminal convictions. The check revealed that Mr. Ramirez was a felon. Agent Tall then requested and received certified documents that verified felony convictions. Gov’t Exs. 8-11. Agent Tall further testified that, when he went to arrest Mr. Ramirez at a motel, he asked him if he had a Social Security card and Mr. Ramirez denied having one. Among the items collected from the nightstand in the motel room, however, was a Social Security card in the name of Cosme Sanchez Ramirez. 3. Immigration and Customs Enforcement Dwight Glidden, a deportation agent with the Immigration and Customs Enforcement (ICE) Office, also testified. Agent Glidden stated that he is primarily responsible for monitoring the status of aliens in the United States, that is, individuals who, by definition, are not United States citizens or nationals. The United States Citizenship and Immigration Services Bureau maintains an alien file for Mr. Ramirez. The file reveals that Mr. Ramirez was born in Havana, Cuba in 1963, and that he first arrived in the United States in 1980. The file reflects that he applied for asylum and after his application was denied, he was ordered excluded and deported back to Cuba. Cuba, however, has refused to accept persons who arrived in the United States from the Mariel Boatlift in 1980, and Mr. Ramirez’s deportation order was never executed. Mr. Ramirez has never been a United States citizen. Mr. Ramirez’s alien file contains evidence that Mr. Ramirez knew that he was a citizen of Cuba. On January 28, 2005, Mr. Ramirez documented his citizenship as “Cuba” on a federal form. Gov’t Ex. 17-A. On March 2, 2005, on his application for employment authorization, Mr. Ramirez again listed Cuba as his country of citizenship. Gov’t Ex. 17-C. When Agent Glid-den met Mr. Ramirez in March 2005, he instructed him to carry his alien registration card with him at all times. The alien registration card further confirms that Mr. Ramirez is a citizen of Cuba. B. The Defense 1. Mental Health Problems Prior to Leaving Cuba Mr. Ramirez testified that he was first hospitalized when he was thirteen years old. According to him, two or three weeks after being hospitalized, he escaped during outdoor recreational time. Mr. Ramirez stated that when he was placed in the hospital, a judge ordered a mental health evaluation. Tr. II at 116: 10-14. Mr. Ramirez recounted two instances in which he had tried to hurt himself while still in Cuba. When he was seven years old, he took a bullet cartridge and stuck it in his foot with a hammer to escape teasing at school for not wearing shoes. Tr. II at 116:21-25. When he was either eight or nine, he threw himself from a second floor “[bjecause I was disturbed. I was bothered. I was upset. I was losing control of myself. I was losing control of my mind.... [I][d]idn’t have control of myself, my person. I didn’t know what I was doing.” Tr. II at 117:13-20. He testified that the thought — to throw himself off of the roof — just suddenly came into his mind. Mr. Ramirez explained that there “are times when I think ... I’m able to hear people speaking to me from another world. There are times when I think I can hear them. And I believe that I have the power to do what they tell me to do.” Tr. II at 118:18-22. Mr. Ramirez was part of the Mariel Boat Lift from Cuba in 1980. When asked whether he knew why he was forced to leave Cuba, he replied: Because in Cuba, I will tell you the truth, Fidel Castro doesn’t want anyone who has mental problems, doesn’t want anyone who has no education, doesn’t want criminals, doesn’t want homosexuals, doesn’t want lesbians. Castro wants a perfect place. That’s why they threw me out of Cuba and had me come here. Tr. II at 114:14-19. 2. Mental Health Problems Since Coming to the United States Mr. Ramirez recounted various instances in which he had tried to hurt himself after he arrived in the United States and then received mental health treatment. In 1984, Mr. Ramirez was sent to a hospital in California for cutting himself on the wrist. At some point in 1993, in New York, Mr. Ramirez began feeling like dead people were coming after him and following him everywhere. As recounted by Mr. Ramirez, he first went to a government building in Manhattan to seek help or deportation to Cuba, but then went running down into the subway. The police caught him in the subway and brought him to Bellevue Hospital. He was transferred to a hospital in Brookline, due to a shortage of beds, and recalls remaining at the second hospital around five or six weeks. In 1999, Mr. Ramirez was hospitalized in North Carolina, after he tried to “jump over the turnpike.” Tr. II at 137:25; 138:1-5. Mr. Ramirez also spoke about two incidents in Virginia in 2000, one in which he threw himself in front of a car and the other in which he laid down on the road waiting for a car to drive over him. On the first occasion, after the police arrived, they took him to the hospital, where he maintained he stayed for approximately three weeks. Sometime between 2001 and 2002, in Atlanta, Georgia, he heard voices “telling me to lie down on the train tracks, and it was better to die than continue to live....” Tr. II at 130:24-25. Mr. Ramirez stated that he was hospitalized in Atlanta for three days following this incident. Mr. Ramirez said that on another occasion in Georgia, “I grabbed the — -the bottle of pills and I tried to — I took them all with a bottle of alcohol — liquor to kill myself.” Tr. II at 132:2-16. 3. Mental Health Problems in Maine Mr. Ramirez was staying with a Mend in Portland, Maine for about forty days before coming to Bangor. He testified that, during that period, he did not feel well, was suffering from depression, and. “had a lot of hallucinations and [ ] felt that they were pursuing me and that they were following me everywhere.” Tr. II at 126:10-13. “They” he said was “people from another planet or the government, people.” Tr. II at 126:14-15. At some point while he was living in Portland, the police took him to the hospital. As recounted by Mr. Ramirez, the police had responded to a report by his friend’s nephew that Mr. Ramirez had grabbed a knife to kill himself. He recalled grabbing the knife but could not say what he intended to do with it because he “had taken alcohol” and “smoked a lot of marijuana” and his “brain wasn’t working well at the time like it is now.” Tr. II at 127:6-9. When asked to elaborate on his condition at the time, Mr. Ramirez stated: I felt that I couldn’t go out in the street. I couldn’t go outside. I felt really awful when I was out in the street and there were a lot of voices in my head. And there were a lot of voices that were telling — saying a lot of things to me, and they were telling me to go to Atlanta because I have doctors in Atlanta. Tr. II at 127:12-18. Although Mr. Ramirez initially stated that, since being in the U.S., he had not heard voices before this incident, he went on to chronicle the history provided above, including the episode where he heard voices in Atlanta. The police took Mr. Ramirez to the hospital a second time sometime between March and April 2005, while he was staying at the Broadway Crossing Shelter. He stated: “I was going to cook. They said that I was trying to light a fire in the kitchen, that I didn’t know that I couldn’t cook. I was crazy.” Tr. II at 129:12-15. As a result, the police took Mr. Ramirez to Maine Medical Center, where he was held for a few hours and released. Ultimately, Mr. Ramirez ended up in Bangor. He testified that he was actually planning on traveling by bus from Portland to Atlanta, to visit with his doctor there and receive medication. When he arrived at the bus station, he met a man and a woman. Mr. Ramirez said that he had been drinking prior to his arrival at the bus station and, upon meeting the couple, the three began taking pills and drinking liquor together. According to Mr. Ramirez, the couple told him that he should not go to Atlanta, that they had a house where he could stay, and that they were going to solve his medication problems by connecting him with places that provide medication and help. When they arrived in Bangor later that evening, however, the couple tried to steal his money. When he prevented them from doing so, they left him on the street near the Ramada Inn. At approximately six a.m., because he was not feeling well, Mr. Ramirez took a cab to Eastern Maine Medical Center and presented at the emergency room. The emergency room staff refused care after smelling liquor on his breath. He asked the cabdriver to take him somewhere with a lot of people, in the hope that someone might speak Spanish; the cabdriver took him to a grocery store. Mr. Ramirez testified that, at this point, his mental state was “[pjretty bad.” Tr. II at 150:7. He recollected: I had like a panic attack. It felt like a panic attack. And then I got over that and then I started to feeling very depressed and then I started to hear the voices.... I was — had started to hear the voices and they got worse when I was got to [the grocery store].... The same thing was happening, the voices were — were in my head again, and I was — I started feeling that I was losing control over myself. And I was starting to feel that something was going to happen to me. Tr. II at 150:9-25. After being asked to leave the grocery store: I called a taxi. And the voices in my head said I should kill myself. So why would I want to keep living in a world like this, that no matter where you go they treat you like a dog. And so that’s how it happened that I went to Frati’s to see if I could buy a firearm to see if I could end the — end the life that I had been living, the years that I have. Tr. II at 151:15-22. Mr. Ramirez asked the cabdriver to bring him somewhere that sells firearms. He stated that he told the cabdriver that he wanted the gun to defend himself, because “I can’t tell everybody about my problems, everybody in the street... .You’re not going to tell them that you’re going to kill yourself. Nobody says that to anybody.” Tr. II at 152:12-19. Mr. Ramirez further stated that he lied to the cabdriver about his reasons for wanting a gun because if he had told him the truth, “then they’re going to call the police and they’ll — they’ll arrest you.” Tr. II at 152:21-22. 4. Hearing Voices Mr. Ramirez explained that “[tjhere are times when [the voices] are all together in my head. Sometimes it’s hard to tell what they’re saying ... And sometimes I hear music in my head also, as though it were a radio. And I have this music in my head and I can’t turn it off....” Tr. Ill at 21:2-7 (Docket # 186). He was unsure of who the voices were, but suggested that they may be the voices of people who have died. The voices spoke both Spanish and English. Mr. Ramirez testified that he does not typically tell others that he hears voices. He has felt it futile to share this information with mental health professionals since they were not going to help him. At the time of trial, in January 2007, Mr. Ramirez had not heard voices for some period of time. He posited that this may be “because of the medicine they’re giving me.... Since I’m talking (sic) medicine, I don’t hear the voices anymore.” Tr. II at 141:13-20. Mr. Ramirez stated that he also feels generally better now and agreed that he feels better than he did in April 2005. Even in his present state, however, Mr. Ramirez was unsure whether he would be able to resist voices urging him to do something. He explained that “it’s not a thing you can take out of your head to feel some peace,” and that he has “tried enough [to resist the voices] and I wasn’t able to.” Tr. II at 163:23-24, 164:5. He stated later, on cross-examination, that singing, or speaking with someone who wants to help him, helps keep the voices away. 5. Family History of Mental Health Issues Mr. Ramirez testified that both his older brother and deceased mother had mental health issues. He elaborated, saying that sometimes when he went to his mother’s house, she would “get really nervous and be shaking. She would have nerve problems. And so I couldn’t do anything for her, and I would take her to the hospital.” Tr. II at 143:14-16. He stated that he learned about his older brother’s mental health problems because “he was in the hospital while I was in Cuba and after I came here from Cuba, he was in the hospital.” Tr. II at 144:10-12. 6. Alcohol and Drug Use Mr. Ramirez stated that he has used marijuana, cocaine, pills and Valium. Regarding alcohol, he could not recall how much he was typically consuming before being arrested. He only stated that there “are times when I will drink every day and there would be times when I don’t drink at all.” Tr. Ill at 18:9-10. He acknowledged, however, that he had been drinking on April 13, 2005: I had some beer, and I had a six pack, and I don’t really remember. But when the police arrested me, they found three empty cans of beer. I drank three of them in a glass with ice, those last three. I don’t remember. I could have drank — let me think. Let me see if I remember. I began drinking in Portland before coming up here to Bangor. I had some hard liquor, beer also and pills. Here I — I drank also. I can’t remember exactly how much it was. It could have been a six pack. It could have been two. Tr. Ill at 18:25-25, 19:1-8. Mr. Ramirez stated that when he consumes alcohol, “[sjometimes I think that I’m a different person, that I am not the same. I’m someone else.” Tr. Ill at 19:9-11. Mr. Ramirez was unable to recall whether he told his doctor, Dr. Martinez, that he has always known that “drinking gets [him] into trouble all the time,” but he conceded that he may have said that. Tr. Ill at 20:15-18. 1. Mr. Ramirez’s Account of Frati the Pawnbrokers Mr. Ramirez’s memory of his interaction with Mr. Frati differs significantly from Mr. Frati’s recollection. At one point, Mr. Ramirez stated that he was unable to remember certain details of the exchange because “at that moment ... my memory wasn’t very good. My mind wasn’t very good.” Tr. II at 153:23-25. Nevertheless, Mr. Ramirez testified that Mr. Frati helped him fill out Form 4473, that he informed Mr. Frati he did not know how to read or write well in English, and that Mr. Frati was showing him where to answer and “where I had to put yes or no.” Tr. II at 156:12. Mr. Ramirez stated that Mr. Frati helped him with almost all of the questions on the form. Specifically, Mr. Ramirez stated that Mr. Frati: [S]tarted to read with his finger, then he — he pointed to where it says yes, no and he pointed for me to — to write in the answer.... He told me where it says in the — in the — on the spot in the square to put yes, no, no, no. Some of [the questions] I understood, but not all of them because I didn’t even try to read the paper, what the paper said there. I didn’t know it was something like that because if I had, I wouldn’t have done anything like that. Tr. II at 157:15-25,158:1-3. The following exchange occurred between Mr. Ramirez and his attorney: Q. Did you fill [Question 8] out? A. Yes, of course. Q. Did you know that you were marking the section that said American Indian or Alaskan Native? A. As I explained before, that kind of thing I didn’t even read. I was just told and went boom, boom, boom and filled them out as told. That’s the way it was done. I don’t know if I was doing it well or not. Q. Are you an American Indian? A. I am Cuban. Q. So you’re not an American Indian or Alaskan native? A. No, no. Q. Were you attempting to fool Mr. Frati into thinking you were a Native American? A. No, no. Tr. II at 160:20-25, 161:1-17; see also Gov’t Ex. 3. Similarly: Q. Have you ever been naturalized as a citizen in the United States? A. No. Q. You are citizen of Cuba? A. I was a citizen of Cuba. I don’t know now if I am. I’m still a citizen of Cuba because I’m not there. Q. What country are you a citizen of? A. Now I don’t know what country is my country of citizenship. I don’t know. Tr. II at 122:21-25,123:1^. At another point, Mr. Ramirez testified that he did not believe that he had a choice in completing Form 4473: I was going along with the voices that I heard, ordering that I complete this or finish this, that I had to complete this and get — -buy the weapon to kill myself. I was serving — how can I say this? I was following orders that I complete this in order to fulfill this order. I wasn’t acting with my mind clearly. If I had been aware of what I was doing, I wouldn’t be sitting here now talking about this. Tr. II at 166:15-23. Similarly, Mr. Ramirez maintained: “I didn’t know what I was writing about, but if I knew what it had said, I ... wouldn’t have been filling it out. I wouldn’t have done such a thing like this. I didn’t know the importance of this paper. I didn’t know what it meant.” Tr. II at 165:6-11. Still, he stated that his purpose in filling out Form 4473 was “to get a gun and kill myself. That’s what I was trying to do.” Tr. II at 167:22-23; he stated that his purpose in looking at the firearm was “to buy it, you know.” Tr. II at 168:14-15. On cross-examination, the Government asked Mr. Ramirez how he knew to respond with answers that generally related to the question if he did not read the form. For example, Mr. Ramirez wrote “Miami, FL” as his place of birth and “407 Cumberland Ave, Bangor, Penobscot, ME” as his address. Gov’t Ex. 3. He was unable to say whether Mr. Frati had provided him with those answers. The Government then introduced an attested copy of a judgment from June 2001, confirming Mr. Ramirez’s conviction for giving a false name when arrested. Gov’t Ex. 18. 8. Dr. Angel Martinez: Direct Examination The defense presented the expert testimony of clinical psychologist, Angel Martinez. Dr. Martinez is employed with the Department of Corrections in Florida, although he also maintains a small private practice. At the Department of Corrections, Dr. Martinez conducts parole evaluations, which address such concerns as whether an inmate would qualify as having a mental disease or defect that would preclude him from being paroled, whether those issues might endanger society, and whether ongoing substance abuse issues need to be addressed. Dr. Martinez performed a comprehensive psychological evaluation of Mr. Ramirez. Def. Ex. 2, 3. In preparation for his evaluation, he conducted two interviews of Mr. Ramirez — one on February 6, 2006 and the second on February 10, 2006 — and reviewed his medical, psychiatric, police, prison, and immigration records. He also interviewed Dr. Corona, a Cumberland County jail psychiatrist, three Cumberland County corrections officers, Wanda Johnson, LCSW, Detective Tall, and Dr. Cosme Benitiz, a long-time friend of Mr. Ramirez. Def. Ex. 2. Dr. Martinez produced a report dated February 15, 2006, in which he concluded: It is the opinion of this examiner, based on reasonable scientific certainty that the defendant was not suffering from an active phase of a severe mental illness or defect at the time of the alleged offense. Mr. [Ramirez] possessed the capacity to appreciate the wrongfulness of his behavior and conform his behavior to the requirement of the law. There is no evidence, in my opinion, that his offense was in any way a product of active mental illness or mental defect, which would not allow him to appreciate the nature and quality or wrongfulness of his acts. Def. Ex. 2 at 28. However, Dr. Martinez produced a second, markedly different report on August 29, 2006, in which he stated that Mr. Ramirez’s presentation was consistent with that of individuals diagnosed with “Alcohol-Induced Psychotic Disorder with Hallucinations.” Def. Ex. 3 at 12. He concluded that “it is possible that he might not have understood the wrongfulness of his actions due to an alcohol-related psychosis.” Id. at 13. Finally, he opined that Mr. Ramirez’s mental disease or defect is “clearly” severe. Id. Dr. Martinez explained that between February and August, he received a few more medical records but, more importantly, he did some research on alcohol-induced psychosis. He stated that he was inclined toward alcohol-induced psychosis, in part, because some of the additional documents he received in December were from Dr. Corona, who maintained a diagnosis of alcohol-induced psychosis. He testified that in re-reviewing Mr. Ramirez’s records in further depth, he discovered a “pattern that [he] believed to be alcohol-induced psychosis.” Tr. Ill at 95:5-6. Specifically, Dr. Martinez said: [W]hat struck me was that there is a connection here between Mr. Sanehez-Ramirez’s alcohol problems, which I think is alcohol dependence and underlying schizophrenic disorder, which I think is well-documented — I think that’s well-documented given the — given the history, the psychiatric history, and the interaction of alcohol consumption with that underlying schizophrenic disorder. Tr. Ill at 97:15-22. Dr. Martinez stated that alcohol-induced psychosis is a dual diagnosis, meaning that an individual has two major issues, which interact. According to Dr. Martinez, Mr. Ramirez has an issue with alcohol dependence as well as “a schizophrenic-type disorder.” Tr. Ill at 98:12-13. As used in his report, “underlying schizophrenic traits” refers to the fact that: [Mr. Ramirez] has had 11 diagnoses of schizophrenia ranging from schizoaffec-tive, which is one of the diagnoses that I gave him, to paranoid schizophrenia to disorganized schizophrenia. He’s had bipolar disorder with psychotic features. He’s had delusional disorder. He’s had organic personality — he’s had several diagnoses there, which make it kind of difficult to really pinpoint exactly, not having him over time in a controlled setting, what that schizophrenic picture looks like.... So it could be schizoaffec-tive. It could be certainly paranoid schizophrenia. It could be disorganized .... Tr. IV at 5:11-25, 6:1 (Docket # 187). Ultimately, Dr. Martinez stated that various types of schizophrenia are consistent with Mr. Ramirez’s symptoms, which include “disorganized thinking, a break with reality, a quick decompensation of cognitive function and mental status changes ... visual hallucinations ... delusions ... disruptive behaviors, disorganized thinking, tangential, circumstantial, lucid ideas, flightive ideas and so on.” Tr. IV at 6:11-17. On direct examination, Dr. Martinez sought to clarify that “the primary diagnosis here, in my professional opinion, is schizophrenia. The alcohol dependence, alcohol-induced psychosis is a secondary diagnosis, which contributes heavily to the symptom manifestation of hallucinations and some of the things that Mr. Cosme Ramirez indicated he experienced resulting from consumption of alcohol.” Tr. IV at 4:23-25, 5-1-4. Although he acknowledged that “[a]nybody can have an alcohol-induced psychosis.... The diagnosis becomes more powerful when you have a known alcohol dependence.” Tr. Ill at 100:23-25. Essentially, a diagnosis of alcohol-induced psychosis can be stronger or weaker, depending on other criteria, such as “familial history as well as the environmental history.” Id. at 101:9-14. In Dr. Martinez’s professional opinion, Mr. Ramirez presents other criteria that render the diagnosis of alcohol-induced psychosis more powerful, including “[t]he early history of alcohol use, the alcohol dependence, the alcohol diagnoses, the treatment, his reporting again to numerous hospitals with ... mental status changes after consuming alcohol.” Tr. Ill at 101:19-23. Mr. Ramirez’s alcoholism interacts with his schizophrenic traits in a way that “seems to be sort of the kindling in the fire. It seems to lower his threshold for the presentation of those [more] overt schizophrenic traits, particularly the — the auditory hallucinations, the visual hallucinations, disorganized thinking.” Tr. IV at 6:22-25, 7:1. According to Dr. Martinez, what “causes the psychosis is more the — the withdrawing from alcohol than actually being drunk, if you will. It is the constant back and forth of introducing the alcohol to the brain with withdrawal, with withdrawal.” Tr. Ill at 99:1-5. Dr. Martinez noted within his review those “occasions where [Mr. Ramirez] has not been drinking and he’s hearing voices and seeing things.... ” Tr. Ill at 102:1-3. Specifically, he complained of hearing voices and seeing things, even in the controlled environments of the Cumberland County jail, the Bureau of Prisons, and group homes. Dr. Martinez suggested that some of the treatment, or lack thereof, of Mr. Ramirez may have focused too much on the alcohol as opposed to his possible underlying psychiatric disorder. He believed that, in light of Mr. Ramirez’s presentation, some of the hospital discharges without treatment were premature and explained that this was a common problem with individuals with a dual diagnosis. He said: “It’s very hard when you have a poor historian, homeless individual, who at times may be viewed as malingering to find a bed, who has alcohol dependence, schizophrenia, a poor historian and tends to malinger, I could completely understand where it’s a diagnostic conundrum, absolutely.” Tr. TV at 23:11-16. a. Malingering Dr. Martinez testified that he did discover evidence of malingering when he examined Mr. Ramirez. Tr. IV at 26:12-15. Dr. Martinez explained that there are tests to determine whether an individual is malingering and, based on these tests, he concluded that Mr. Ramirez was malingering. Tr. IV at 29:9-11. He stressed, however, that just because a person malingers does not mean that he or she does not have a psychological disorder. Tr. IV at 30:17-19. When asked whether Mr. Ramirez was trying to fake alcoholism, Dr. Martinez stated that he did not believe so, in part, because Mr. Ramirez denies having an alcohol problem: [T]here was a strong history of alcohol use and involvement. And I was always struck with the fact that Mr. Ramirez, and I think even to this day, denies having an alcohol problem, an alcohol-dependent problem, that struck me. [He has a] long history. Again, going back from age seven, use of alcohol, the number — I don’t have — have the figure on hand, but the number of times that he presented to hospitals with mental status changes with alcohol involvement. So that’s — that’s—that’s something. Tr. Ill at 86:24-25, 87:1-12. Moreover, many reports and records suggest that he was incoherent on account of intoxication. In any event, Dr. Martinez stated that Mr. Ramirez’s malingering had no bearing on his conclusions, since they were based entirely on his re-review of Mr. Ramirez’s records. b. Medical Conclusion Ultimately, when asked “it’s your opinion, to a reasonable professional certainty, that Mr. [Ramirez] was suffering from [alcohol-induced psychosis with underlying schizophrenic traits] on April 13, 2005, the date of the incident in this matter?” he responded “I think that was a possibility, yes sir.” Tr. TV at 37:1-9. He further testified that in Mr. Ramirez’s mental disease or defect was severe. 9. Dr. Martinez: Cross-Examination On cross-examination, the Government probed the discrepancies between Dr. Martinez’s first and second reports. a. The February 15, 2006 Report Dr. Martinez agreed on cross-examination that he knew that his initial evaluation was important, that is was important for him to be thorough and careful, that the report would bear on critical issues, and that those issues, in turn, would bear on Mr. Ramirez’s guilt or innocence. Dr. Martinez further acknowledged it was his understanding that the February report would be shared with the defense attorney, but not with the Government. Yet, he issued his February 15, 2006 report, which reads: It is the opinion of this examiner, based on reasonable scientific certainty that the defendant was not suffering from an active phase of a severe mental illness or defect at time of the alleged offense. Mr. Sanchez Ramirez possessed the capacity to appreciate the wrongfulness of his behavior and conform his behavior to the requirement of the law. There is no evidence, in my opinion, that his offense was in any way a product of active mental illness or mental defect, which would not allow him to appreciate the nature and quality or wrongfulness of his acts. Def. Ex. 2 at 28. Dr. Martinez’s first report also contains considerable detail about Mr. Ramirez’s malingering. As he testified on direct examination, Dr. Martinez conducted a number of tests to determine whether Mr. Ramirez was malingering. His report, however, goes into considerably more detail: This [test] can be used to test the validity of a memory complaint. The underlying principle is that the individual who consciously or unconsciously wishes to appear impaired will fail at a task that all but the most severely brain damaged or mentally retarded patients perform easily. Mr. Sanchez-Ramirez’s score on this measure suggest a clear attempt on his part to portray himself as experiencing memory impairments that do not actually exist. Id. at 17. The report goes on: Mr. Sanchez-Ramirez provides further evidence of a response style characterized by attempts to exaggerate and fabricate difficulties by his responses on three other tests which were administered to him in Spanish_ Mr. Sanchez-Ramirez’s responses on the Structured Interview of Reported Symptoms provided considerable evidence that the defendant was motivated to exaggerate and/or fabricate psychotic-spectrum symptoms during the course of his interview with this writer. This was accomplished by his endorsement of rare symptoms (symptoms that occur very infrequently in bona fide patients) symptom combinations (psychiatric problems that rarely occur simultaneously), blatant symptoms (symptoms that untrained individuals are likely to identify as obvious signs of a major mental illness), selectivity of symptoms (indicates indiscriminant endorsement of psychiatric problems), and severity of symptoms (endorsing of blatant and subtle symptoms at an extreme or unbearable severity) .... Perhaps the best evidence of an attempt on the defendant’s part to appear more impaired than is actually the case came from the Structured Inventory of Malingered Symptomatology (SIMS) ... Mr. Sanchez-Ramirez’s SIMS profile indicates that he exaggerated and/or fabricated across each of the SIMS scales (Psychosis, Neurological Impairment, Amnestic Disorder, Low Intelligence, Affective Disorders).... [Finally] Mr. Sanchez Ramirez was administered the Personality Assessment Inventory (PAI).... His results suggested an element of exaggeration or complaints and problems. In terms of percentiles, scores above the 70th percentile indicate feigning. Mr. Sanchez-Ramirez’s score was above the 95th percentile .... Thus, there is a reasonable degree of probability that the defendant is feigning or exaggerating his psychiatric symptoms. Id. at 17-19. In addition to his interviews and testing of Mr. Ramirez, Dr. Martinez’s first report also includes a good deal of information from secondary interviews. For example, Dr. Martinez interviewed Corporal Pickr-eign, a corrections officer at the Cumberland County jail and the report includes Corporal Pickreign’s statements that “I don’t see any psychotic behaviors. He will act-out, in that way when he does not get what he wants,” and “[h]e speaks good English, but selectively. If he doesn’t want to do something or is mad, he will pretend not to understand you or what you are asking him.” Id. at 13. Dr. Martinez also interviewed Mrs. Wanda Johnson, Mr. Ramirez’s social worker who has been working with him since September 2005. Dr. Martinez’s February report states that she remarked that Mr. Ramirez “is very manipulative— he wants to make a mental health case for his charges....” Id. at 13. Mrs. Johnson reported that “she has not seen any psychotic behavior when she meets with Mr. [Ramirez].” Id. Finally, the report reads, the “police interviews indicate that all the witnesses at the time of the offense did not perceive Mr. [Ramirez]’s thinking or behavior as scrambled or disorganized.” Id. at 28. It goes on: He did not behave as an individual out of touch with reality or out touch with his behavior. Mr. [Ramirez] had the forethought to falsely answer questions regarding his criminal status and citizenship, which, had he answered truthfully, would likely have precluded him from obtaining the firearm. He had the temporal cognition at the time, regardless of the situation or environment to understand the cause and effect of his actions. His behavior was goal directed, coherent and organized with the intention of possessing a firearm. Mr. [Ramirez]’s actions at the pawnshop and at the time of his arrest demonstrate that he had taken prior actions (telling the taxi to wait for him), understood that what he was doing was wrong (telling the pawnshop owner that he wanted a gun that could be concealed from the police, false statements on the ATF form, putting a firearm in his waistband and covering the firearm) and tried to avoid apprehension (did not produce the Social Security card when asked by the police).... His actions would indicate a significant degree of ... planned, controlled behavior as well as an indication of ability to appreciate that his behavior was wrong. Id. b. The August 29, 2006 Report Dr. Martinez’s August report is strikingly different from the one he produced in February. Along with his receipt of additional records pertaining to Mr. Ramirez, Dr. Martinez affirmed that he received an Order from this Court, discussing the definitions for insanity and competency and the legal thresholds. Dr. Martinez further testified he understood the second report would be shared with the Government. Nevertheless, unlike his February report, Dr. Martinez’s August report omits all information he gathered from Mr. Ramirez during the interviews and testing, including his proclivity to malinger. Similarly, the August report omits the lengthy section of secondary interviews, including the multiple impressions that Mr. Ramirez is highly manipulative. Dr. Martinez explained these omissions, saying that he considered the second review of Mr. Ramirez’s case an entirely separate evaluation. According to Dr. Martinez, these interviews were omitted because the August report was based exclusively on his re-review of the records with an eye towards a pattern consistent with alcohol-induced psychosis. As such, he maintained that the information he gathered from these interpersonal exchanges was secondary and that the test results suggesting malingering had no bearing on his second evaluation. Although Dr. Martinez repeatedly stressed that his second report was an evaluation based exclusively on his review of Mr. Ramirez’s records, Dr. Martinez conceded on cross-examination that much of the second report still came directly from Mr. Ramirez, not from his records, including all or portions of the sections titled “Relevant History,” “Medical History,” “Substance Use,” “Criminal History,” and “Psychiatric History.” Def. Ex. 3. In addition to the sizable contributions to the August report obtained directly from Mr. Ramirez, the Government further suggested to Dr. Martinez that the records on which he based his second evaluation were permeated with Mr. Ramirez’s tendency to malinger, since the medical records were a reflection of his own presentation to the various health care providers. For example, the Government introduced a report from Grady Health System in Atlanta, concerning the episode in which Mr. Ramirez claims to have thrown himself onto the subway tracks in a suicide attempt. The record reads: “[Patient] says he’s suicidal. Patient says this as he smiles and laughs. Patient clearly manipulative, saying he needs a place to stay.” Tr. IV at 98:12-14; Gov’t Ex. 24. Dr. Martinez acknowledged that there were three or four references among the records where other treatment providers believed Mr. Ramirez was malingering his symptoms; he said: “The point’s well-taken that there have been plenty, plenty of mental health providers who have questioned the veracity of the presentation.” Tr. IV at 72:17-20. c. Medical Conclusion Ultimately, Dr. Martinez conceded that he did not actually reach a diagnosis in his August report. Rather, he concluded: “given [] Mr. [Ramirez]’s description of the circumstances (heavy drinking, hearing voices, feeling depressed and suicidal), which let (sic) him wanting to purchase a gun to kill himself it is possible that he might not have understood the wrongfulness of his actions due to an alcohol-related psychosis.” Def. Ex. 3. Dr. Martinez agreed that he does not have an opinion as to whether Mr. Ramirez actually suffered from a severe mental disease or defect at the time of the offense, saying “I put the question there of possibility, could be.... And his behavior could be explained as ... alcohol-induced psychosis on top of a schizophrenic disorder.” Tr. IV at 91:19— 20, 22-24. Moreover, Dr. Martinez conceded that a diagnosis of alcohol-induced psychosis or schizophrenia or of schizophrenic traits or of schizoaffective disorder would not necessarily mean that a person is unable to appreciate the nature and quality or wrongfulness of his acts. He further agreed with the statements that “in most situations the clinical diagnosis of a DSM IV mental disorder is not sufficient to establish the existence for legal purposes of a mental disorder, mental disability, mental disease, or mental defect,” and “the fact that an individual’s presentation meets the criteria for a DSM IV diagnosis does not carry any necessary implication regarding the individual’s degree of control over the behaviors that may be associated with that disorder.” Tr. TV at 105:10-22. 10. Dr. Martinez: Re -Direct Examination Dr. Martinez acknowledged that he had changed his mind after the initial report, but insisted that to do so was “not a bad thing.” Tr. IV at 116:10-12. He explained that a psychologist “can always go back and ... look at things that you might have missed and look at other information ... [in a] different light.” Tr. IV at 116:13-16. He also agreed that simply because hospitalization records have evidence of malingering does not render them “totally unreliable.” Tr. TV at 116:20-25; 117:1-3. Ultimately, when asked: “At the time of the alleged offense, could Mr. [Ramirez] been suffering from a mental disease or defect that was severe?” Dr. Martinez responded: “He could have.” Tr. IV at 118:17-20. When pressed whether it was “more likely than not” that Mr. Ramirez was suffering from a “mental disease or defect that was severe,” Dr. Martinez opined that he was. He described the condition as schizophrenia. Tr. IV at 118:21-25. C. The Government’s Response: Dr. Christine Scronce In response, the Government presented the expert testimony of Dr. Christine Scronce, a clinical psychologist at the Federal Medical Center in Devens, Massachusetts. Like Dr. Martinez, Dr. Scronce is a forensic psychologist; Dr. Scronce primarily does evaluations for the court on issues of competency, sanity and dangerousness. Tr. IV at 124:19-21. As part of her responsibilities at Devens, she is charged with evaluating a defendant’s competency and mental condition at the time of an alleged offense. She explained that the inquiry is “whether or not this person has a mental illness or some sort of mental abnormality, but also specifically whether they had those symptoms at this particular time that the crime occurred.” Tr. IV at 129:4-9. If the conclusion is that the person was suffering from a mental illness at the time of the incident, the doctor then explores “what were the symptoms and how severe were they, and did they impact the person’s ability to understand what he was doing or the wrongfulness of his behavior, so there has to be a nexus there, as well.” Tr. IV at 129:12-17. For example, then, someone could have a mental disorder, but not be suffering from any symptoms at the time of the offense. Tr. IV at 129:21-25; 130:1-2. Mr. Ramirez arrived at Devens on May 5, 2005, only a few weeks after the alleged offense. Tr. IV at 126:17-21. Dr. Scronce engaged in eight hours of interviews with him, conducted four hours of testing, and gathered observations from staff members. Tr. IV at 141:22-25; 142:1-7. She reviewed a number of Mr. Ramirez’s records, including the medical records from Maine General. Tr. IV at 134:18-25; 135:1-21. She elaborated that these were of particular significance because they present a snapshot of Mr. Ramirez’s clinical status just prior to the alleged offense, Tr. IV at 136:10-18: the record reflects that he was admitted and shortly thereafter discharged with a diagnosis of alcohol abuse and antisocial personality disorder, but there was no mention in the medical record of any symptoms of mental illness. Tr. IV at 137:4-12. Dr. Scronce also viewed the videotape taken from Frati’s the Pawnbrokers. Tr. IV at 138:5-6. She stated: “When I reviewed the — the videotape later, I just noticed the things that I didn’t see that I was expecting to see. I didn’t see anything unusual in his demeanor or his dress. I didn’t notice anything unusual about his gait or his dexterity.” Tr. IV at 138:14-18. Finally, Dr. Scronce reviewed both of Dr. Martinez’s reports. She described the February report as “comprehensive,” and “well-formulated, well put together.” Tr. IV at 160:1-6. Based on her evaluation, Dr. Scronce concluded that Mr. Ramirez did not suffer from a severe mental disease or defect at the time of the incident. Dr. Scronce explained: [M]y assessment of his — of his presentation at Devens, I concluded that he was malingering. That doesn’t rule out the possibility that someone may have a mental illness, as I noted in my report. However, it does make it more difficult to determine what symptoms are real and what are false. And I found the same thing when I was going back over the records. When somebody has a long psychiatric history and they’re malingering in your evaluation, it’s — it can be difficult to tease-out what’s what when you’re looking at the — at the records. The easiest thing to do sometimes is to just, say, give them a catch-all diagnosis, like psychotic disorder not otherwise specified. I do that a lot because sometimes it’s so difficult to tease-out the etiology and somebody could be using substances, somebody could be — have a real mental illness, somebody could have medical problems. And when you’re trying to look through this mountain of information, it’s so difficult to sort through. So one thing that I really considered in this case was to give a diagnosis like that, psychotic disorder not otherwise specified, but when I started looking at the records carefully, even though he had gotten these diagnoses in the past, I was just not finding a lot of support for — for the diagnosis. So it wasn’t really described, you know, what exactly were the symptoms that he was demonstrating at that time.... I also was aware when I talked to him about his history. He spontaneously reported to me, a lot of people think I’m faking. A lot of people think that I just go to the hospital to get shelter, and that’s not true. I thought that was unusual because I hadn’t, you know, expressed any, you know, suspicion of him at that point. It was funny that he would just spontaneously say that. And when I reviewed the records, I saw a lot of that. I saw a lot of his contacts with the mental health services that had to do with trying to get shelter.... This was the pattern that I saw in the records. And so while I really considered just giving this sort of catch-all diagnosis ... I started to realize, I don’t — I didn’t think that he had any kind of mental illness at all. I think that he was — as I said in my report, using the mental health system to try to get his basic needs met. And that was a pretty strong statement that I made and I didn’t make that lightly, but I just felt that in good conscience I could not say that I felt that I thought he had a mental illness. Tr. IV at 144:16-25, 145:1-19, 146:5-25, 147:1-8. Dr. Scronce thought that Mr. Ramirez was malingering and found “many examples of ... manipulative behavior.” Tr. IV at 154:9-10. She testified that Mr. Ramirez was acutely interested in what her report would say. He “repeatedly questioned me about what I was going to say in the report. And he suggested different interpretations of the data for me.” Tr. IV at 153:10-13. Mr. Ramirez told Dr. Scronce “that I should write in the report that he was incoherent, that he was intoxicated. ...” Tr. IV at 153:14-16. He also “gave many other explanations about his offensive behavior that were all things that would reduce his culpability, for instance, blaming the pawn shop owner and saying that he couldn’t read English and he didn’t know what he was filing out. So he had many different explanations for his behavior.” Tr. IV at 154:23-25, 155:1-3. When Dr. Scronce refused to reveal the substance of her report to Mr. Ramirez, he went to other clinicians, asking them to share Dr. Scronce’s impressions with him, telling them that she was too busy to tell him. Another example she provided was: [O]ne evening he told the officer he was hearing voices and he wanted to talk to a clinician. My colleague, Dr. Schols, who’s another forensic psychologist, went to see him and assess the situation, and he said that he wanted to move back to a different unit where he had his own room. And he said that he was taking all these medications and he was worried that the medications would prevent him from defending himself if he got into a fight or prevent him from going to the dining hall. And what was described in the note and when I talked to my colleague was he was very insistent about this. And eventually they did give him a different room on that unit, gave him a single room, that he was satisfied with that, but that was one example where using the symptom of, I’m hearing all these voices. And there seemed to be a pretty clear motivation, external motivation for reporting that. Tr. TV at 152:10-25,153:1-2. According to Dr. Scronce, Mr. Ramirez’s acting out is further evidence of his manipulation: So take, for instance, the smearing of feces, which is an extreme behavior, obviously, and in Mr. [Ramirezj’s case, the — what’s described in the records is when he doesn’t get his needs met right away, when he has something that he wants and he doesn’t get it, this is his way of dealing with that situation, you know, forcing the correctional staff to clean up the mess. So as opposed to somebody that’s just completely disorganized and isn’t able to care for himself and doesn’t know what he’s doing. Tr. IV at 150:23-25, 151-.1-7. Finally, Dr. Scronce pointed out comments in one of the Grady medical records: [I]n the discharge summary that describes him saying that he was going to tell his other homeless friends that they should report that they’re suicidal or homicidal so they can come to the hospital because you get a bed and food and it’s much better than being in jail. So even then there was quite a bit of suspicion about the genuineness of his presentation. Tr. TV at 159:1-8. Notably, Dr. Scronce had not received this report when she made her assessment of Mr. Ramirez, but testified that the report was consistent with her own assessment. Well after fashioning her conclusions, Dr. Scronce observed Mr. Ramirez testify during trial. She described “very obvious inconsistencies between the story he gave in his testimony and what he told me. The whole story about hearing voices to tell him to — telling him to commit suicide, he had none of that kind of report when I interviewed him. There was nothing about that at all. He told me that he just went there to browse and he, you know, was — didn’t really describe the reason why he went to the pawn shop.” Tr. IV at 139:13-21. Dr. Scronce also noted Mr. Ramirez’s persistent statements of his own veracity, saying: “when I’m doing an assessment, that is a red flag when somebody repeatedly tells me, I’m being honest with you. I wouldn’t lie to you.” Tr. TV at 140:13-15. She explained that people frequently are not telling the truth when they repeatedly give assurances that they are. Tr. TV at 140:3-18. Moreover, Dr. Scronce stated that Mr. Ramirez’s testimony of his experience with command auditory hallucinations — that they just overwhelmed him and that he could not resist their commands — is “an atypical description” of those symptoms; typically, people retain “some control of their behavior” and do not feel as though they must “blindly follow whatever they’re told to do.” Tr. TV at 140:19-25; 141:1-3. Similarly, Mr. Ramirez’s testimony that the voices were constant is also “atypical;” usually, “voices are intermittent or people can do something to reduce the severity of the voices.” Tr. IV at 141:4-11. Dr. Scronce stated that “when somebody tells me that the voices are just constant and they have to do whatever the voices say, those are just suspicious signs.” Tr. IV at 141:9-11. Notwithstanding suspicious behavior, however, Dr. Scronce stated that clinicians must frequently take patients at their word. Tr. IV at 148:1-2. She explained that many, if not most, clinicians simply do not have time to obtain records from other facilities or conduct an extended evaluation. For example, if a patient were to arrive and say that he is hearing voices telling him to kill himself, the clinician would have to act right then and “people that want to use the mental health care system for shelter know that. They know that, what they need to do to get themselves admitted to a hospital.” Tr. IV at 148:6-9. Similarly, if a clinician, at some point, does make a diagnosis of unspecified schizophrenia, subsequent clinicians will continue with that presumptive diagnosis because they do not have any additional information or the time to perform a full evaluation. Dr. Scronce stated that, as a result, the fact that a person has been prescribed a particular medication does not mean that that person has a serious mental illness. Tr. IV at 149:2-9. On cross-examination, defense counsel probed this final point. Dr. Scronce admitted that, given the serious side effects of antipsychotic medications, prescribing physicians should be very careful not to prescribe them unless they are necessary. Further, when Mr. Ramirez arrived at De-vens he was on antipsychotic medication; over the course of his forty-five day evaluation at Devens, Mr. Ramirez remained on antipsychotic medication; and, Mr. Ramirez ultimately left Devens on the same antipsychotic medication. Again, however, Dr. Scronce explained: It’s clinically appropriate when somebody comes in and say they have a history of psychosis and they says they have a history of having auditory hallucinations and they come in on an antipsy-chotic medication, it’s understandable that someone would continue the medication, even if information is found later on to call that diagnosis into question. So they make the clinical decisions they have to make with the information they have available at the time. Tr. TV at 172:21-25, 173:1-4. Moreover, Dr. Scronce did not produce her report, or share her findings with the prescribing clinicians, until after Mr. Ramirez had left Devens. Still, she stated: [Pjeople have the perception that we can do experiments on people and just take them off medication to see what will happen. That’s not what a psychiatrist would do. So even if they did have this information about the malingering and suspect that that was the case, they’re probably not going to discontinue it right before someone leaves because-they want to do some follow-up to make sure and to make sure that they’re taken off the medication in the appropriate way. So that’s — that’s why when we have them for a short period, there’s usually not many or any changes in the medication regimen, if they can help it. Tr. TV at 174:19-25,175:1-6. Finally, Dr. Scronce acknowledged that, simply because a particular type of behavior is atypical for a particular psychological diagnosis, the presence of that behavior does not rule out that diagnosis; that alcohol could increase the likelihood of experiencing auditory hallucinations in a person who has been diagnosed with schizophrenia and who tends to experience command auditory hallucinations; that alcohol could also increase the intensity of those hallucinations; that people sometimes do give in to auditory commands; that if a person suffered from alcohol-induced psychosis but then went through withdrawal after a period of not drinking, then perhaps the symptoms of that psychosis would not be outwardly evident; and, that Mr. Ramirez was not drinking while at Devens. D. The June 11, 2007 Argument After the evidence closed, the parties submitted written argument and the Court further allowed counsel to present oral arguments, which were scheduled for June 11, 2007. When Mr. Ramirez arrived at the courthouse, he was beside himself. Prior to the arguments there was considerable banging in the holding cell near the courtroom and, at a conference of counsel, the United States Marshal expressed serious safety concerns, noting that Mr. Ramirez was virtually uncontrollable. As this was not a jury trial and no evidence was to be taken, the Court acceded to the Marshal’s recommendation that he be shackled for the hearing. See Moore v. Ponte, 186 F.3d 26, 35 (1st Cir.1999) (noting that physical restraints may be used to control unruly defendants in criminal trials, but only as a last resort); United States v. Pina, 844 F.2d 1, 8 (1st Cir.1988) (concluding that in a jury trial context, brief exposure of the defendant in shackles to some of the jurors is not inherently prejudicial). When the proceedings began, Mr. Ramirez engaged in a loud, continuous rant, a foul and abusive harangue against all present. After entering, the Court waited to see if Mr. Ramirez would calm down. He did not. In accordance with Illinois v. Allen, the Court asked Mr. Ramirez if he could behave himself and repeatedly warned him that it would have him removed from the courtroom, if he persisted. 397 U.S. 337, 350, 90 S.Ct. 1057, 25 L.Ed.2d 353 (1970) (holding that “a defendant can lose his right to be present at trial if, after he has been warned by the judge that he will be removed if he continues his disruptive behavior, he nevertheless insists on conducting himself in a manner so disorderly, disruptive, and disrespectful of the court that his trial cannot be carried on with him in the courtroom.”). Mr. Ramirez continued unabated with his incoherent and profane screed and showed no signs of controlling himself. As Mr. Ramirez was incapable of remaining in the courtroom without disrupting the proceedings, the Court ordered him removed and the parties made their final presentations in his absence. II. DISCUSSION A. Mental Health Evidence To Negate Mens Rea Preliminarily, Mr. Ramirez has argued that psychological evidence—apart from the psychological evidence offered for the insanity defense—may be used to negate mens rea. He is correct. As the First Circuit has noted, “in principle there should be no bar to medical evidence that a defendant, although not insane, lacked the requisite state of mind.” United States v. Schneider, 111 F.3d 197, 201 (1st Cir.1997). However, there are significant limitations to the applicability of such evidence. Even though the First Circuit has “not yet adopted the general/specific intent distinction under IDRA,” United States v. Santos-Bueno, No. 04-40023-FDS, 2006 WL 240060, *5, 2006 U.S. Dist. LEXIS 6275, at *15 (D.Mass. Jan.5, 2006), it has said that “[t]o be admissible, such evidence must directly negate intent.” United States v. Marenghi, 893 F.Supp. 85, 90 (D.Me.1995). Thus, “mental conditions or defects would rarely, if ever, negate a general intent requirement, given that general intent demands only proof of knowledge with respect to the actus reus of the crime.” Santos-Bueno, 2006 WL 2