IN THE COURT OF APPEALS OF IOWA

No. 16-1491

Filed February 22, 2017

IN RE THE MATTER OF C.D.,

Alleged to be Seriously Mentally Impaired,

C.D.,

Respondent-Appellant.

________________________________________________________________

Appeal from the Iowa District Court for Polk County, Scott D. Rosenberg, 

Judge.

Respondent appeals the district court order finding she was seriously 

mentally impaired. AFFIRMED.

Alexander D. Smith of Parrish Kruidenier Dunn Boles Gribble Gentry 

Brown & Bergmann, L.L.P., Des Moines, for appellant.

Thomas J. Miller, Attorney General, and Gretchen W. Kraemer, Special 

Assistant Attorney General, for appellee State.

Considered by Mullins, P.J., and Bower and McDonald, JJ.
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BOWER, Judge.

Respondent C.D. appeals the district court order finding she was seriously 

mentally impaired. We find there is clear and convincing evidence in the record 

to show C.D. had a mental illness, lacked sufficient judgment to make 

responsible decisions about her treatment, and was likely to inflict serious 

emotional injury on those close to her if she was allowed to remain at liberty. We 

affirm the decision of the district court.

I. Background Facts & Proceedings

On May 29, 2015, C.D.’s husband, M.D., filed an application alleging C.D. 

was seriously mentally impaired pursuant to Iowa Code section 229.6 (2015). In 

the application, M.D. stated C.D. told him she believed he and their children were 

actually body doubles and not her real family. She accused M.D. of leaving the 

parties’ baby at an animal shelter for dogs to use as a toy. C.D. also felt the 

oldest daughter was using a secret sign language to signal other people. C.D. 

was refusing psychiatric treatment. M.D. stated, “I fear for the mental health of 

our children with her around them, especially our oldest daughter.”

M.D. and C.D. have three children, ages eight, five, and two. The oldest 

child is in therapy to deal with problems arising from C.D.’s statements the child 

was not C.D.’s biological child but was instead a double. The children are the 

subject of Child in Need of Assistance proceedings in juvenile court due to the 

mother’s mental health problems. C.D. believed M.D. was not her husband but 

was a look-alike supervisor placed in her home by the Iowa Department of 

Human Services (DHS) to monitor her behavior.
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Dr. Adnan Iqbal diagnosed C.D. with bipolar disorder with manic and 

psychotic features and delusions. A magistrate determined C.D. was seriously 

mentally impaired, finding C.D. “is likely to inflict serious emotional injury on 

family members and others who are unable to avoid her.” C.D. had inpatient 

treatment for a period of time and then, on July 14, 2015, was transferred to 

outpatient treatment.

On June 20, 2016, in a periodic report, Rebecca Nunn-Ryan, a psychiatric 

nurse practitioner who was treating C.D., stated C.D.’s condition had deteriorated 

because she was not taking her medication. M.D. filed a new application alleging 

C.D. was seriously mentally impaired. C.D. was again saying her husband and 

children were body doubles. M.D. noted the oldest child was in counseling 

because of C.D.’s statement the children were not her real, biological children but 

were doubles. Dr. Laura Seal, a psychiatrist, wrote a letter stating, “Due to 

ongoing delusions and psychotic symptoms, the patient is considered a risk to 

self or others.” A magistrate determined C.D. was seriously mentally impaired 

and needed impatient treatment.

C.D. appealed to the district court, and a trial de novo was held, pursuant 

to section 229.21(3). Sheila Aunspach, a DHS social worker, testified C.D.’s 

delusions caused harm to the children’s self-identity and could cause emotional 

injury. She stated the mother’s statements could affect the children’s ability to 

develop bonds and attachments. Aunspach testified the mental illness of a 

parent could be considered an adverse childhood experience, which could 

impact a child’s emotional well-being, leading to issues such as depression, 
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substance abuse, and obesity. Aunspach testified she kept in contact with the 

oldest child’s therapist, who stated the child had problems regulating her 

emotions. Also, the child’s emotions did not match her statements. The child 

exhibited problems with stress, coping skills, and self-identification. The child’s 

therapist recommended the child continue in therapy to address these issues.

Dr. James Dennert, a psychiatrist, testified C.D. had been diagnosed with 

delusional disorder. He stated she had no insight into her condition but was 

treatable. Dr. Dennert stated, “So it is my opinion that, without treatment, her 

delusions will continue and likely worsen and that this will present a significant 

danger to her children and others who come in contact with her, specifically her 

husband and those who can’t avoid contact with her.” He testified if the oldest 

child was having problems regulating her emotions and exhibiting adequate 

coping skills this could indicate serious emotional injury. He also expressed 

concern the child might be experiencing depression.

Nunn-Ryan testified at her last appointment with C.D., on August 1, 2016, 

C.D. told her as soon as C.D. found her real children she was going to take them 

out of state and hide them. C.D. wanted to change the children’s names and not 

permit them to see their father. C.D. also told Nunn-Ryan she had no intention of 

taking medication. C.D. did not appear for her next scheduled appointment with 

Nunn-Ryan. Nunn-Ryan testified, “I am also concerned on how this is affecting 

the children having their mother believe that she is not their mother, that they are 

body doubles. I would think that would, you know, eventually start playing a 

big—a role on the children’s self-esteem and psyche.” 
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C.D. testified she did not have a mental illness, so had no need to take 

medication. She asked for DNA testing of the children to show they were not her 

biological children. She stated she loved the children, however, and expressed 

an interest in adopting them.

The district court entered an order finding there was clear and convincing 

evidence to show C.D. was seriously mentally impaired. The court found C.D. 

suffered from the mental illness of delusional disorder, which was treatable. The 

court also found C.D. was not capable of making responsible decisions about her 

treatment. Furthermore, the court found C.D. was “likely to inflict serious 

emotional injury on her family members who lack reasonable opportunity to avoid 

contact with [her] if she is allowed to remain at liberty without treatment.” The 

court noted, “Mother’s mental health had affected [the oldest child’s] coping skills, 

contributes to [the child’s] stress and distress levels and impacts [the child’s] selfacceptance.” The court additionally noted the evidence C.D. was planning to 

take the children out of state, hide them, and change their names. C.D. now 

appeals the decision of the district court.

II. Standard of Review

Challenges to the sufficiency of the evidence in involuntary commitment 

proceedings are reviewed for the correction of errors at law. In re B.B., 826 

N.W.2d 425, 428 (Iowa 2013). An allegation of serious mental impairment must 

be proven by clear and convincing evidence. Iowa Code § 229.13(1). “Clear and 

convincing evidence is less burdensome than evidence establishing proof 

beyond a reasonable doubt, but more burdensome than a preponderance of the 
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evidence.” B.B., 826 N.W.2d at 428. “It means that there must be no serious or 

substantial doubt about the correctness of a particular conclusion drawn from the 

evidence.” Id.

While the elements of serious mental impairment must be established by 

clear and convincing evidence, the district court’s factual findings are binding on 

appeal if they are supported by substantial evidence. In re J.P., 574 N.W.2d 340, 

342 (Iowa 1998). “Evidence is substantial if a reasonable trier of fact could 

conclude the findings were established by clear and convincing evidence.” Id.

III. Merits

Iowa Code section 229.1(17) defines “seriously mentally impaired,” as 

follows:

“Seriously mentally impaired” or “serious mental impairment” 

describes the condition of a person with mental illness and because 

of that illness lacks sufficient judgment to make responsible 

decisions with respect to the person’s hospitalization or treatment, 

and who because of that illness meets any of the following criteria:

a. Is likely to physically injure the person’s self or others if 

allowed to remain at liberty without treatment.

b. Is likely to inflict serious emotional injury on members of 

the person’s family or others who lack reasonable opportunity to 

avoid contact with the person with mental illness if the person with 

mental illness is allowed to remain at liberty without treatment.

c. Is unable to satisfy the person’s needs for nourishment, 

clothing, essential medical care, or shelter so that it is likely that the 

person will suffer physical injury, physical debilitation, or death.

The definition of serious mental impairment has three elements. The 

respondent must be found to have (1) a mental illness, (2) to lack “sufficient 

judgment to make responsible decisions with respect to the person’s 

hospitalization or treatment,” and (3) to be likely, if allowed to remain at liberty, to 

inflict physical injury on “the person’s self or others,” to inflict serious emotional 
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injury on those close to the person, or to be unable to satisfy the person’s 

physical needs. J.P., 574 N.W.2d at 343 (quoting In re Foster, 426 N.W.2d 374, 

376-77 (Iowa 1988)).

The case before us is based on a finding there was clear and convincing 

evidence in the record to show C.D. was likely to inflict serious emotional injury 

on members of her family or others who lacked a reasonable opportunity to avoid 

contact with her if she was allowed to remain at liberty without treatment. See

Iowa Code § 229.1(17)(b). The phrase “serious emotional injury” is defined as 

“an injury which does not necessarily exhibit any physical characteristics, but 

which can be recognized and diagnosed by a licensed physician or other mental 

health professional and which can be causally connected with the act or omission 

of the person who is, or is alleged to be, mentally ill.” Id. § 229.1(16). A finding 

of emotional trauma is not sufficient. J.P., 574 N.W.2d at 344.

The term “likely” means “probable or reasonably to be expected.” In re

Oseing, 296 N.W.2d 797, 801 (Iowa 1980). “This element requires a predictive 

judgment, ‘based on prior manifestations but nevertheless ultimately grounded 

on future rather than past danger.’” Id. (citation omitted). The threat the patient 

poses must “be evidenced by a ‘recent act, attempt, or threat.’” In re Mohr, 383 

N.W.2d 539, 542 (Iowa 1986).

We determine there is substantial evidence in the record to support the 

district court’s conclusion C.D. was likely to inflict serious emotional injury on her 

family if she was allowed to remain at liberty without treatment. The evidence 

showed C.D.’s oldest child had an injury causally connected to C.D.’s statements 
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in front of the child to the effect the child was not her biological child, but was a 

body double, and M.D. was not the child’s father, but was also a body double. 

The evidence showed the serious emotional harm the child suffered and was 

likely to suffer in the future, which was causally connected to the mother’s 

statements. See Iowa Code § 229.1(16). The testimony Dr. Dennert, a 

psychiatrist, and Nunn-Ryan, a psychiatric nurse practitioner, showed the child’s 

condition “can be recognized and diagnosed by a licensed physician or other 

mental health professional.” See id.

C.D. engaged in a recent overt act by threatening to take the children out 

of the state, hide them, and change their names, thereby keeping them from 

M.D. and those she believed had switched her children for body doubles. A 

recent over act may be an act, attempt, or threat. Mohr, 383 N.W.2d at 542. 

C.D.’s threatened action would likely cause the children serious emotional injury, 

as well as potential physical injury.

We affirm the decision of the district court finding C.D. is seriously 

mentally impaired.

AFFIRMED.