Carl is accused of the assault and battery of an elderly woman after breaking two bones in her cheek as well as knocking out several of her teeth. When the time comes for Carl's trial, he informs his attorney that he engaged in this attack because he saw the devil in his victim, and that he still believed that she was Satan. Carl could not cooperate or contribute to his defense, enter into a plea bargain, and did not recognize that his delusions were unreal. Which label would be most appropriate to describe Carl before the trial?