20 July 2011

Dewani case: latest odd claims

The Shrien Dewani case just gets odder and odder. The entire body of psychiatric evidence seems to be coming from the defence lawyers. CyberShrink questions their findings.


The Shrien Dewani case just gets odder and odder. The entire body of psychiatric evidence seems to be coming from the defence lawyers. Where are the prosecution lawyers?

This extradition case must be very expensive for South Africa, but the money could be wasted unless they use major expertise in psychiatry and psychological trauma. Clearly the supposed mental state of Dewani is the cornerstone of his defence. The court should not rely solely on experts called by a wealthy defence.

 Most experts would try hard to be objective if called to assist the court in such a case, but they can lose objectivity fairly easily, especially if all the questions they are asked and all the information they receive, come from the defence. Some available to testify are frankly mercenaries, as we've seen in some notable South African cases over the years, and they will find whatever the lawyer who is paying them wants them to find.

Very curious diagnoses
As I pointed out before, his first diagnoses were minor and temporary, and apparently not made according to proper criteria. Then we were told the diagnoses were depression and PTSD. He's been in hospital for months now, and appropriate treatment should have shown good results by now.

But apparently there've been no benefits at all, as the diagnoses seem from the most recent reports, to be becoming ever more complicated and alarming.

Who's paranoid?
We've been told this week that he is paranoid. This is not usually a feature of either PTSD or depression. Where an accused (whether actually innocent or guilty) is hated or resented by many people, it may be essentially normal for them to be aware that people might wish them harm. That isn't paranoia, which requires excessive and inappropriate, usually baseless, concerns of that type.

Suicidal threats manipulative?
We keep getting told that Dewani is suicidal. This can be a feature of depression, but should by now, with proper treatment, have ceased to be a real risk. Yet he is still on careful suicide watch. Then we hear he's  suggested he might postpone his suicide until he reaches South Africa, so as to make our authorities look stupid. This sort of threat is typical of someone exploiting the threat manipulatively.

There is no objective test for being suicidal, and the court is relying on what Dewani chooses to tell them, and the interpretation they place on his obvious behaviours. Come to think of it, if Dewani is sincerely suicidal, would he not achieve that most efficiently, according to his own team's previous arguments, by embracing extradition and picking fights in a SA prison? 

Suspicious claims
The repeated claims that he must be excused from attending the court hearings are very peculiar, and rarely made in usual practice (especially for someone who has supposedly been properly treated for months). His advocate said it would be "positively inhuman" to require him to attend. Even people with unquestionably severe PTSD and depression with whom I have worked, have been able, willing and wanting to attend court hearings. Claims that he's barely able to speak or walk are distinctly odd and unconvincing.

There's now a strange claim that he feels dreadful when riding in a vehicle, in the presence of other people, or when he hears loud noises, due to what sound like claims of experiencing flashbacks of what happened to his wife. But according to the evidence thus far, nothing notable happened to his wife while he was in any vehicle, but only after he had been ejected, so he would have witnessed nothing. This complaint sounds potentially fabricated, and definitely does not match any likely presentation of PTSD. Such symptoms in genuine PTSD are related to key aspects of the actual trauma experienced.

And now there's a claim that he's "hearing voices", said to be heard "outside his hospital room". This is not typical of how most patients hear voices pathologically, and not a usual feature of either of his diagnoses. Might he be learning symptoms from other patients? What reading matter has he had? Hospitals are generally noisy, and filled with voices outside one's room. All the claims reported are based entirely on what he says, and seem to be believed by his doctors without any scepticism whatever.

Ineffective treatment
Why do his two, common diagnoses seem to be totally resistant to treatment? We hear he has refused to follow some of the advice given, such as attending group therapy. Is it certain he is actually taking the drugs provided? 

He shuffles dramatically into and out of court, and his doctor calls this "psychomotor retardation" (a sign of depression which really ought to have lifted by now). Yet he works out obsessively in the gym. Why is the court not more actively suspicious of these claims, and of what may be a cynical performance?

If as the SA advocate claimed, he does "sit-ups, press-ups, skipping and even weight training", why would his doctor not see how totally it contradicts claims of "psychomotor retardation"? Apparently, hospital staff even confiscated his skipping rope fearing he'd induce muscle strain! 

Not following advice
There are comments that he may be showing raised levels of an enzyme Creatine Kinase (which can leak from damaged muscle), and this may be being used, controversially, to claim it'd be dangerous to give him antidepressants. To allow a patient to behave in a way that causes muscle damage and prevents needed treatment, is profoundly peculiar. It could be so very obviously self-serving and intended to delay his extradition and trial.

There's a puzzling quote that his doctor said "he was aware of suggestions Mr Dewani might have been trying to deliberately raise his enzyme levels but added: 'I don’t believe this man is faking the rise in CK.' "

I don't understand this. While a raised CK level isn't in itself faked, it can be engineered or caused by a patient/ accused motivated to do so. It is unacceptable to naïvely assess the evidence in such a case at face value if one ignores the obvious context and self-preservation needs of the patient. Apparently he is not now receiving antidepressants, though they'd be valuable in treating both of his diagnoses.

The court heard he was not following some of the medical advice he receives, such as avoiding group therapy.

Claiming benefits on the basis of an illness for which one is refusing part of the recommended treatment is like killing your parents and then claiming in mitigation that you are a poor sad orphan.

Contrary to evidence quoted as from a forensic specialist in court, such behaviours are NOT typical of the conditions he is claimed to suffer from, and deliberate manipulation cannot be ruled out in such cases. I cannot understand or agree with the assertion that his condition(s) would necessarily be worsened by extradition to SA where he might receive proper treatment with less indulgence - and less freedom to sabotage it.

If Dewani is in any way exaggerating or manipulating his symptoms so as to limit treatment and dramatize his claimed illness, then a court should be extremely reluctant to allow this to succeed. One suspects if extradition were refused, and if he was to be found unable to stand trial and the charges dismissed, one might see a remarkable recovery, as he wouldn’t want to remain in a secure hospital, behaving in this way for any longer than necessary to suit his purposes.

What's the Plot?
One wonders what purpose may be served by this heavy emphasis on claims about his mental state. These are not really relevant to the issue of deportation nor would they convincingly suggest that he was not guilty of whatever charges he might face. Is the strange and unconvincing emphasis on his utter inability to attend court, meant to form the basis of claims that he's unfit to stand trial, as unable to attend or to properly instruct his defence team? If so, this would be a set of medical and legal claims unique in the history of forensic psychiatry.

His team is already claiming that he'd be considered unfit to stand trial in a British Court. Dr Paul Cantrell, who was quoted in recent reports as treating him, is a specialist forensic psychiatrist, though not known as an expert in PTSD as such. I am amazed to read that Dr Cantrell apparently described Dewani's combination of two diagnoses (PTSD and depression) as "fairly uncommon" and said he had never treated anyone in this state before. In fact this combination is common, and anyone with much experience in treating PTSD would have have often treated this. I don't understand, either, Dr Cantrell's evidence that "his two disorders were hampering the treatment of each other", a quite unique viewpoint, as there is a fruitful overlap between the treatments needed for these conditions. Maybe he's been misquoted in the press.

 (Professor M.A. Simpson, aka CyberShrink, Health24 July 2011)






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