Jared Loughner is headed back to a federal prison hospital in Missouri for another four months of mental treatment in an effort to make him competent to stand trial on charges related to Tucson’s Jan. 8 shooting rampage.

Loughner, who was wearing a white T-shirt and khaki pants and sporting short brown hair, sat shackled at the defense table with a blank look on his face throughout most of Wednesday’s federal court hearing to determine whether further treatment would allow him to assist in his defense against the 49 counts he is facing in federal court stemming from the shooting spree at U.S. Rep. Gabrielle Giffords’ Congress on Your Corner event. Six people were killed, including federal Judge John Roll and a 9-year-old Christina-Taylor Green, and and 13 others were wounded, including Giffords, who is still recovering from being shot through the head.

Loughner’s somber appearance was a stark change from his earlier court appearances, where he often sat with a broad smile. In his last appearance, in May, Loughner disrupted the courtroom with an incoherent outburst that led to him being removed from the courtroom.

After a seven-and-a-half-hour court hearing, U.S. District Court Judge Larry Burns ruled in favor of prosecutors, who had requested that Loughner continue to receive treatment at the federal facility in Springfield, Mo. But he shortened their request for eight months of treatment to just four months.

“The court finds that measurable progress toward restoration has been made,” Burns said.

In making his ruling to allow doctors more time to attempt to restore Loughner to competency, Burns said was relying on the likelihood of a “substantial probability” that they would be able to get Loughner to a point where he could understand the charges against him and assist in his own defense.

Burns noted that Loughner’s smirk was gone and he seemed to be paying attention to the proceedings.

“He appears to be more connected,” Burns said.

Much of the day’s testimony came from Dr. Christina Pietz, a psychologist who has been treating Loughner.

Pietz’s testimony provided a window into Loughner’s life since he was arrested after being tackled at the scene by several members of the crowd while he was attempting to reload his handgun after he’d emptied the first clip.

Pietz said when Loughner first arrived at the prison hospital, he often rambled incoherently—a sign of schizophrenia she described as “word salad” or “poverty of speech.”

He suffered from auditory and visual hallucinations, sometimes hurled a chair around his cell, and expressed severe distrust of his attorneys, saying that he believed they were out to blackmail or extort money from him. On one occasion, he spat at a member of his legal team.

Pietz said Loughner was “devastated” when she told him he suffered from mental illness.

“He didn’t want to be mentally ill,” she said.

Once the the prison staff started medicating him against his will on June 21, Pietz said she saw some slight changes in Loughner’s mood, but “nothing significant.”

But on July 1, a federal appeals court ordered prison staff to stop the forcibly medication. In the wake of that ruling, Pietz said that Loughner became “much worse.” He would sob uncontrollably and pace his cell for hours on end. He developed a blister on his foot that became infected; the infection spread up his leg before he’d allow the prison staff to treat it.

At one point, he went 50 hours without sleeping and began to exhibit poor hygiene, including penetrating his anus with a finger or a spork and smearing feces on his bed and clothes.

Loughner’s breakdown grew so severe that prison staff concluded he posed a danger to himself or others and began forcibly medicating him again with a cocktail of anti-psychotic and anti-depressive drugs. Pietz said that Loughner was passively cooperative about taking the medication; although he objected to having to take it, he still would swallow it each day.

Pietz testified that the medication has improved Loughner’s mental state.

“He’s not where he should be … but there’s certainly improvement,” Pietz said.

For example, Loughner now understands that Giffords survived the shooting.

“He’s less obsessed with that,” Pietz said. “He understands that he murdered people and he talks about that. He talks about how remorseful he is.”

On cross-examination by Loughner’s defense attorney, Judy Clarke, Pietz said that she thought the fact that Loughner now trusted his legal team was a sign that his mental state was improving.

“The mere fact that he visits with you indicates that’s improved,” Pietz said. “Previously, when he was unwilling to go visit with you, it was because he was paranoid.”

Burns said that the defense team would have one week to provide a briefing objecting to the ongoing forcible medication of Loughner against his will.