AFFIRM and Opinion Filed April 5, 2019 

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In The 

## Court of Appeals Fifth District of Texas at Dallas
No. 05-18-01452-CV No. 05-18-01453-CV IN THE BEST INTEREST AND PR OTECTION OF B.J., Relator On Appeal from the Probate Court No. 3 Dallas County, Texas Trial Court Cause Nos. MI-18-03203 & MED-18-80461 

### MEMORANDUM OPINION Before Chief Justice Burns and Justices Molberg and Nowell Opinion by Chief Justice Burns B.J. appeals from a judgment committing her to temporary inpati ent mental health services and an order permitting her psychiatrist to administer psychoac tive medication during the term of her commitment. In her appeal of the commitment judgment, appe llant contends the trial court’s findings that she was likely to cause seri ous harm to herself o r others are not supported by legally and factually sufficient evidence. In her appeal of the medica tion order, appellant contends the medication order should be reversed because it depends upon the insufficiently supported commitment judgment. We affirm both cases.
B ACKGROUND On October 25, 2018, Dr. Muhammad Haqqani, one of appellant’s t reating psychiatrists, filed an application for temporary court-ordered mental health services for appellant and a supporting physician’s certificate. On that same date, the Sta te filed a motion for an order of–2– protective custody requesting that appellant be detained at Dal las Behavioral Health Hospital (“DBHH” hereinafter) pending a probable cause hearing. The tri al court granted the State’s motion and signed an order of protective custody pending trial. On Oc tober 26, 2018, Dr. Haqqani filed an application to administer f our types of psychoactive medicat ion to appellant. On that same date, a second psychiatrist treat ing appellant, Dr. Bachir Debb a, filed a supporting physician’s certificate. Both Haqqani and Debba diagnosed appellant with schizoaffective disorder, bipolar type, and each psychiatrist certified that appellant was mentally ill , was likely to cause serious harm to herself or others, was sufferi ng severe and abnormal mental, em otional or physical distress, was deteriorating in her ability t o function independently and unab le to provide for her basic needs, and was unable to make a rational and informed decision regardi ng treatment. Haqqani stated he had been treating appellant for twenty-seven days. He describe d appellant as psychotic, unable to care for herself, and noncompliant with medications. According to Haqqani, appellant believed hospital staff members were sex ually assaulting her in her slee p, cutting her hair, and filing down her teeth and nose. Appellant believed an “electrostimulator” had been implanted in her brain. Haqqani further described appellant as unwilling to bathe becau se she wanted to preserve DNA evidence of the repeated sexual assaults. Debba certified he had been treat ing appellant for twenty-eight days. Debba reported that on October 26, 2018, appellant had told him that an electrostim ulator had been implanted in her head in 2013, that she was being stalked by white men and white women, and that she has been detained for reporting she had be en raped. Debba stated his op inion that appellant was noncompliant with taking her medi cation, was psychotic, and was unable to care for herself. Debba stated that appellant belie ved she was being repeatedly r aped in her sleep, she had called the police several times, she was refusing to bathe because she did not want to wash away DNA–3– evidence, she was paranoid of o thers, and was verbally aggressi ve. Debba describ ed appellant as disheveled, anxious, having diso rganized thoughts, persecutory delusions, and exhibiting poor insight and judgment. On November 15, 2018, the trial court conducted hearings on the pending applications. After hearing testimony from Dr. Haqqani and appellant and cons idering the physician certificates on file, the trial court granted the commitment application and committed appellant for up to ninety days. Immediately following th e commitment hearing, the trial court heard testimony from Haqqani and appellant and then granted the application for an o rder to administer psychoactive medication during the term of the commitment.
S TANDARD OF R EVIEW We apply the same standard of review to both the commitment jud gment and the order to administer psychoactive medication. State ex rel. D.W. , 359 S.W.3d 383, 385 (Tex. App.—Dallas 2012, no pet.). Both orders must be supported by clear and con vincing evidence that shows appellant’s mental health meets specific statutory criteria. Id

. “Clear and convincing evidence is ‘that measure or degree of proof which will produce in the mind of the trier of fact a firm belief or conviction as to the truth of the allegations sought to be established.’” State ex rel. M.P. , 418 S.W.3d 850, 853 (Tex. App.—Dallas, no pet.) (quoting State v. Addington , 588 S.W.2d 569, 570 (Tex. 1979 (per curiam)). In determining whether evidence is legally and factuall y sufficient to meet the standa rd of clear and convincing evidence, we apply a heightened standard of review. In re C.H. , 89 S.W.3d 17, 25 (Tex. 2002). In reviewing for legal sufficiency the trial court’s findings under a “clear and convincing evidence” standard, we consider all of the evidence in the light most favorable to the trial court’s findings to determine whether a reasonable factfinder could have formed a firm belief or conviction that the findings

were true. State v. K.E.W. , 315 S.W.3d 16, 20 (Tex. 2010). We assume the trial court res olved–4– disputed facts in favor of its fin dings if a reasonable factfin der could have done so, and we disregard all contrary eviden ce unless a reasonable factfinder could not have done so. Id

. In our factual sufficiency review, we gi ve due consideration to the ev idence that the factfinder could reasonably have found to be clear and convincing and then deter mine whether, based on the entire record, any disputed evidence that a reasonable factfinder coul d not have credited in favor of the finding is so significant that the factfinder could not reasona bly have formed a firm belief or conviction regarding the truth of the allegations. In re J.F.C. , 96 S.W.3d 256, 266 (Tex. 2002).
O RDER OF I NVOLUNTARY C OMMITMENT The criteria for committing a proposed patient for court-ordere d temporary inpatient mental health services is set fort h in Section 574.034(a) of the healt h and safety code: : The judge may order a proposed patient to receive court-ordered temporary inpatient mental health services o nly if the judge or jury find s, from clear and convincing evidence, that: (1) the proposed patient is a person with mental illness; and (2) as a result of that mental illness the proposed patient: (A) is likely to cause seri ous harm to the proposed patient; (B) is likely to cause s erious harm to others; or (C) is: (i) suffering severe and abnormal mental, emotional, or physica l distress; (ii) experiencing substantial me ntal or physical deterioration of the proposed patient’s ability to f unction independently, which is exhibited by the proposed patient ’s inability, except for reaso ns of indigence, to provide for the p roposed patient’s basic needs, including food, clothing, h ealth, or safety; and (iii) unable to make a rational and informed decision as to whe ther or not to submit to treatment.
T EX

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. § 574.034(a). Clear and convincing evidence under section 574.034(a) must inc lude expert testimony and, unless waived, “evidence of a recent overt act or a contin uing pattern of behavior that tends to confirm” the proposed patient is likely to cause serious har m to herself or to others or is–5– exhibiting distress and deteriora tion of her ability to functio n. See id

. at § 574.034(d). An “overt act” within the meaning of sec tion 574.034(d) includes both phy sical actions and verbal

statements. K.E.W. , 315 S.W.3d at 24. Appellant’s verbal statements can be relev ant to both determining whether she is mentally ill and also to predicting what actions she might take in the future as a result of her mental illness. Id. at 22. A recent overt act must be to some degree probative of the trial court’s finding, but it need not be of s uch character that the overt act standing alone would support the finding. Id. at 24. The recent overt act or continuing pattern of behavior must relate to the criteria on which the judgment is based. D.W. , 359 S.W.3d at 386. The expert testimony must include not only the expert’s opinion that the p roposed patient should be committed but also the factual basis for the expert’s opinion. Id . Merely showing that an individual is mentally ill and in need of hospitalization is no t sufficient. State ex rel. C.C., III , 253 S.W.3d 888, 893 (Tex. App.—Dallas 2008, no pet.). At the beginning of the trial, a ppellant requested a new attorn ey or else to represent herself because her appointed counsel refus ed to present “extremely rel evant” evidence showing that she was being assaulted and raped at DBHH while she was unconscious , that her nose was being shortened, and that she was being poisoned. While Dr. Haqqani was testifying, appellant repeatedly interrupted, includi ng at one point stating she was being detained for reporting to the police that she was raped at DBBH. Eventually, the trial court decided to remove her for the remainder of Haqqani’s testimony. After appellant returned and testified, she interrupted the State’s final argument. Dr. Haqqani, the State’s only witn ess, testified he is a board- certified psychiatrist and had been examining appellant two-to-four times per week since Octob er 3rd or 4th of 2018. He had seen her on the two days preceding the hearing. On days when H aqqani did not see her, appellant was examined by his nurse practitioner.–6– Haqqani testified appellant is a t hirty-year-old female sufferi ng from schizoaffective disorder, bipolar type. On September 29, 2018, appellant was t ransferred to DBHH from Parkland Hospital where she had been br ought by police on a mental healt h warrant because she was found wandering in the street, claiming that she had been sexually as saulted about seventeen times. Haqqani described appellant as very paranoid and talking nonsen se. He has observed her responding to internal stimuli by ta lking to herself as if she is hearing voices although she would deny that when questioned directly. Over the course of his testimony, Haqqani described appellant’s paranoid or delusional behavior. Appellant believed sh e was being sexually assaulted every day in the hospital and that hospital staff were cutting her hair and shortening her nose wh ile she slept. Haqqani testified appellant had not bathed in the two months she had been confine d in the hospital because she did not want to wash away any DNA evidence of the alleged sexual as saults. Her telephone use had to be restricted to calls to her attorney because she was makin g numerous 911 emergency calls to the DeSoto Police Department to report sexual assaults. Haqqan i believed police had responded to one of her calls and come to t he hospital. Appellant believ ed people were trying to poison her. She threw supposedly poisoned water at a nurse. Appellant beli eves she has an electrostimulator implanted in her brain. Haqqani described appellant as aggress ive, spitting on nursing staff, throwing water at them, and cursing at people. Haqqani testifi ed appellant used racial slurs to provoke people. In one incident, appellant verbally provoked a male patient until the patient physically assaulted her, requiri ng the hospital to separate th e patients into separate units. Haqqani offered his opinion that appellant is mentally ill and is likely to cause serious harm to herself, serious harm to oth ers, and she is suffering severe , abnormal, mental, emotional, or physical distress. He affirmed his belief that appellant is det eriorating in her ability to function–7– independently and he testified sh e is unable to make a rational and informed decision as to whether to submit to treatment. Haqqani denied believing that a ppellant was experiencing daily sexual assaults and first testified to his psychiatric opinion that all of appellant’s fi xations regarding sexual assault and rape were delusions. Haqqani testified Parkland Hospital documents showed appellant was given a sexual assault nurse examination at Parkland and the results we re normal. He admitted he did not have the details of that and was not one hundred percent certai n about what Parkland had done for appellant. He admitted he had not performed a sexual assault e xamination of appellant. When asked if the hospital investigated all claims of sexual as sault or rape that appellant had made, Haqqani answered that she is monitored by cameras and staff all the time while she has been in DBHH. Haqqani had not received any report of appellant being sexually assaulted during her stay at DBHH. After defense counsel confronted Haqqani wit h documents showing that on September 11, 2018, an emergency room physician had diagnosed a nd treated appellant for sexual assault and had prescribed four medications for her that are co mmonly given to sexual assault victims, Haqqani admitted it was possible that not all of her r eported sexual assaults from before her hospitalization at DBHH were delusions. Haqqani denied that anyone had cut appellant’s hair or cut her nose during her stay in DBHH. Haqqani knows appellant does not have an electrostimulat or implanted in her brain because appellant had undergone a physical examination when she was admitted to DBHH and that examination did not revea l any foreign device in her body. Haqqani answered negatively when asked if appellant was able to take care of activities of daily living, including eating, sleeping, and hygiene. He stat ed he would be concerned about her causing serious harm to herself if she was not in a structured environment such as the hospital–8– because she is not taking care of her hygiene, is very delusion al, and is provoking and aggravating other people to the point she might be assaulted. Haqqani testified, without ela borating, that appellant has a hi story of mental illness and would not be a candidate for any type of outpatient treatment a t this time. Haqqani believed she was not compliant with any outpatient treatment or medication p rior to coming to DBHH. Appellant had not agreed to take any psychiatric medication whi le at DBHH. It was his expert opinion that appellant should be required to have further obser vation and treatment in a structured environment such as DBHH and tha t this was the l east restrictiv e alternative. Haqqani stated that he had discussed with appellant the possibility of further hosp italization at DBHH and she had responded that she believes she is not mentally ill. Haqqani d escribed appellant as being focused on her allegations about sexual assault and physical mutilation

. When asked why he believed appellant was likely to cause seriou s harm to herself, Haqqani testified appellant’s extremely poor hygiene resulting from her refusal to shower or bathe for two months to preserve DNA evidence of sexual assaults created the possibility that she might develop a urinary tract infection. Haqqani also mentioned appellant wa s not using sanitary napkins during her menstrual cycle. Lastly, Haqqani cited appellant’s efforts to provoke other people as evidence that she is a danger to herself. When asked how appellant is likely to cause serious harm to oth ers, Haqqani testified appellant is at times aggressive , spits on nursi ng staff, throw s water at them, and curses at people. Haqqani testified appellant’s 911 calls to the DeSoto police co uld disrupt their services. Haqqani cited appellant’s use of racial slurs and the attack upon her b y the male patient she had provoked. The assault was captured on video. Haqqani, admitted he was no t present when the assault occurred and was basing his testimony on the video and reports that have been made available to him. He admitted the video did not show her strike the patient who attacked her. He admitted she–9– had not physically str uck any patients or staff and her physica l aggression was limited to spitting, throwing water, and posturing. He agreed appellant has not end orsed any suicidal or homicidal ideation. Appellant testified and strongly disagreed with Haqqani’s diagn osis that she was suffering from mental illness. She testified she had attention deficit h yperactivity disorder (“ADHD”) and had been taking amphetamine for ADHD since she was twenty-three years old. She admitted having seen several psychiatrists for ADHD and she claimed to b e under the care of Houston psychiatrist Aaron Fink. Regarding her allegations of se xual assault, appellant testifie d: Every crime I reported has occurred. Two detectives were assign ed in Dallas prior to me being detained. I have been unable to follow up with thos e detectives because I have been at Dallas Behavioral Center under a detention as wh at you call a Proposed Patient. I have been losing consciousness, getting rap ed and assaulted daily. I have not showered because you are not to shower after a sexual assault until you do examination because then no areas can be collected from areas that you wash for that reason. Appellant denied having any desire to harm herself or others ot her than to follow up with the police about her sexual assault allegations. Appellant adm itted to being involved in altercations with another patient while at DBHH. Appellant admitted she had met with two police officers while she was at DBHH. She indicated that if she was discharge d from the hospital, she would either return to her sister's residence or else go to her mothe r’s vacant house in Conroe, Texas. She testified she would be will ing to take medication prescribe d by Dr. Aaron Fink. In her appeal from the commitment judgment, appellant asserts t wo issues contending the evidence submitted to the trial court does not support findings that she is likely to cause serious harm to herself or to others. She contends the videotaped conf rontation with the male patient is indicative of his own inability to control his behavior. She p oints out that there was no evidence of other patients or staff reacting to her speech with aggressi on. Likewise, appellant questions–10– what harm or injury could occur to herself or others from her s pitting, throwing water, and cursing. While admitting the behavior is “immature and uncouth,” appella nt contends it does not satisfy the State’s burden to prove by clear and convincing evidence th at she poses a substantial likelihood of harm to others. Pointing to the evidence that she had been diagnosed as having undergone a sexual assault and prescribed medication commonly given to vict ims of sexual assault, appellant contends that her complaints about being sexually assaulted mig ht not be entirely delusional and might justify, at least initially, her refusal to tend to her h ygiene. Finally, appellant contends her refusal to take psychiatric medication is not sufficient eviden ce of a possibility of harm to herself or others to justify an i nvoluntary commitment. We need not determine whether the trial court’s findings of the likelihood of serious harm are supported by sufficient evidence. The trial court may orde r a person to receive temporary court-ordered mental health ser vices upon a showing by clear an d convincing evidence that the person is mentally ill and that as a result of the mental illne ss, the person meets any one of three statutory criteria set forth i n section 574.034(a)(2)(A–C). See T EX

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. § 574.034(a)(2); State ex rel. T.M. , 362 S.W.3d 850, 852 (Tex. App.—Dallas 2012, no pet.). The trial court found that the State had proven by clear and convin cing evidence that appellant was mentally ill and her mental state met all three of the statutor y criteria. Appellant does not challenge the trial court’s finding that she is mentally ill. Furthermore, she does not challenge the trial court’s finding that the crite rion of §574.034(a)(2)(C) has been met: that she is suffering severe and abnormal mental, emotiona l, or physical distress; she is deteriorating in her ability to function independently, which i s exhibited by her inability, except for reasons of indigence, to provide for her basic needs, inclu ding food, clothing, health, or safety; and she is unable to make a rational and informed decision as t o whether or not to submit to

treatment.–11– These unchallenged findings are all that section 574.034(a) req uires to uphold the trial court’s determination to commit appellant to treatment. See State ex rel. E.D. , 347 S.W.3d 388, 391–93 (Tex. App.—Dallas 2011, no pet.) (affirming judgment for inpatient mental health services where patient did not contest finding of mental illness and evi dence supported finding that patient met distress and deteriorati on criterion of section 574.034(a)( 2)(C)); see also State for Best Interest and Protection of H.V. , No. 04-18-00291-CV, 2018 WL 6069861, at *5, n.4 (Tex. App.—Sa n Antonio, Nov. 21, 2018, no pet.) (not designated for publicatio n) (because criteria under section 574.034(a)(2) are listed in the disjunctive, there was no need to address trial c ourt’s finding under section 574.034(a)(2)(A) after appe llate court found evidence l egally and factually sufficient under section 574.034(a)(2)(C)). The State’s evidence detailed he reinabove shows appellant is pa ranoid and delusional. She believes she is being continua lly sexually assaulted, having he r nose shortened and her hair cut, has an electrostimulator implanted in her brain, and is being p oisoned by the nursing staff. With the sole possible exception of s exual assaults she allege may h ave occurred prior to her hospitalization, none of those beli efs have any factual basis. As a result of her paranoia and delusions, the evidence shows a ppellant is deteriorating in her ability to function independently. She has not bathed for two months, spits on nurses and hurls “poisoned” water at them, refuse s to take medication, and is so verbally aggressive toward others that she is in danger of being a ssaulted. The evidence further shows that she does not understand that she is mentally ill and has refused to take any medication , preferring instead to focus on her delusions of sexual assault and physical mutilation. Appellant ’s delusions, aggression toward others, refusal to attend to her hygiene, and inability to comp rehend her need for treatment are recent overt acts and represent c ontinuing patterns of behavior spanning two months of observation. We conclude the evi dence is legally and factually sufficient to meet the standard of–12– clear and convincing evidence to show appellant is mentally ill and that she is suffering severe and abnormal mental, emotional, or physical distress; she is deteri orating in her ability to function independently, which is exhibited by her inability, except for reasons of indigence, to provide for her basic needs, including food, clothing, health, or safety; a nd she is unable to make a rational and informed decision as to wheth er or not to submit to treatme nt. See M.P. , 418 S.W.3d at 854– 56 (poor personal hygiene and delusional reasons for not taking antipsychotic medications legally and factually sufficient to satisfy requirements of §574.034(a) (2)(C)); E.D. , 347 S.W.3d at 393 (evidence showing patient enga ged in yelling, spitting, verbal threats, aggression toward others, possibility she could be attacked by someone not understanding her condition, and delusional beliefs leaving her unable to or ganize her thinking, live in so ciety without harming others, and keep a job found legally and factually sufficient to meet requi rements of §574.034(a)(2)(C)). Because appellant does not contest the trial court’s finding un der §574.034(a)(2)(C) and the State’s evidence supports the trial court’s finding by clea r and convincing evidence, we need not consider appellant’s issues regarding the trial court’s fin dings under the other two criteria for commitment. See T EX

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. P. 47.1; E.D. , 347 S.W.3d at 391–93; H.V. , No. 04-18-00291-CV, 2018 WL 6069861, at *5, n.4.
O RDER TO A DMINISTER P SYCHOACTIVE M EDICATIONS As relevant to this case, the trial court may issue an order au thorizing the administration of psychoactive medications to a person who “is under a court orde r to receive inpatient mental health services.” T EX

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. § 574.106(a)(1). The order to administer may be issued “only if the court fi nds, by clear and convincing eviden ce after the hearing: (1) that the patient lacks the capacity to make a decision rega rding the administration of the proposed medication and treatment with the proposed medicat ion is in the best interest of the patient.” Id . at § 574.106(a-1).–13– The trial court conducted the tr ial on the application to admin ister psychoactive medication immediately after rendering its r uling on appellant’s involunta ry commitment. The Court took judicial notice of the commitmen t hearing, of the court’s file, and of the order of commitment. During the medication hearing, Dr. Haqqani again appeared as th e State’s only witness. He testified regarding four types of medications on State’s Exh ibit “A” he wanted to administer to appellant: an antidepressant, antipsychotic, anxiolytic/sedativ e/hypnotic, and mood stabilizers. He testified to the benefits and possible side effects of each cla ss of drugs. He testified he believes the benefits of the medications outweigh the possible side effe cts and he will be able to monitor and adjust appellant’s medica tions if side effects appear. Haqqani indicated that antipsycho tic medication would be used o n a regular basis and the others would be administered as needed. He is not aware she ha s any allergies to the drugs. Haqqani offered his opinion that it is in appellant’s best inte rest to take the medications, they will improve her condition, and her condition will not improve and c ontinue to deteriorate if she does not take them. Haqqani reitera ted his belief that appellant do es not understand that she is mentally ill or that psychoactive medication is necessary. He has attemp ted to explain the benefits and risks of the medications, but she has not agreed to take them. Haqqa ni testified that appellant does not have the capacity to decide whether the medications should be a dministered to her because of schizoaffective disorder. Appellant testified she had not t aken the medications that Dr. Haqqani prescribed at the hospital because she has low blood pressure and a low pulse fro m being poisoned, she believes the medications are inapp ropriate, and she be lieves no one should b e forced to take psychoactive medication for reporting or being a victim of sexual assault. Appellant testifie d she would be willing to see Dr. Aaron Fink a nd take medication for her ADHD. She testified she sees Dr. Fink periodically for treatment with a mphetamine for ADHD. She stat ed that her amphetamine–14– treatments help her be more organized. After hearing the testi mony, the trial court granted the application to administer psychoactive medication in its entire ty and made it coterminous with the commitment order. On appeal, appellant’s sole cont ention regarding the medication order is that it should be overturned if the Court overturns the commitment order. Becaus e we are upholding the commitment order, we overrule appellant’s sole issue in cause n o. 05-18-01453-CV. See E.D. , 347 S.W.3d at 394 (affirming order to administer psychoactive m edication where challenge to order was premised on validity of commitment judgment which cou rt was upholding); see also
H.V. , No. 04-18-00291-CV, 2018 WL 6069861, at *5 (upholding medicat ion order where sole challenge was based on sufficiency of commitment order that app ellate court was upholding); Best Interest of J.L. , No. 14-05-00360-CV, 2006 W.L. 56821, at *6 (Tex. App.—Houston [14th Dist.] Jan. 12, 2006, no pet.) (not designated for publication) (same)

. C ONCLUSION We affirm the trial court’s invol untary commitment judgment and its order to administer psychoactive medication.

181452F.P05 /Robert D. Burns, III/ ROBERT D. BURNS, III CHIEF JUSTICE–15– 

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Court of Appeals Fifth District of Texas at Dallas JUDGMENT

IN THE BEST INTEREST AND PROTECTION OF B.J.

No. 05-18-01452-CV On Appeal from the Probate Court No. 3, Dallas County, Texas Trial Court Cause No. MI-18-03203. Opinion delivered by Chief Justice Burns. Justices Molberg and Now ell participating. In accordance with this Court’s opinion of this date, the judg ment of the trial court is AFFIRMED

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Judgment entered April 5, 2019.–16– 

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Court of Appeals Fifth District of Texas at Dallas JUDGMENT

IN THE BEST INTEREST AND PROTECTION OF B.J.
No. 05-18-01453-CV On Appeal from the Probate Court No. 3, Dallas County, Texas Trial Court Cause No. MED-18-80461. Opinion delivered by Chief Justice Burns. Justices Molberg and Now ell participating. In accordance with this Court’s opinion of this date, the tria l court’s order is AFFIRMED

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Judgment entered April 5, 2019.