By Duncan Mlanjira
Psychiatrist Dr. Olive Liwimbi, who is head of clinical department at Zomba Mental Hospital, has certified that murder and corruption suspect Norman Chisale has no evidence of any psychiatric disorder.
The former director of security services for former State President, Peter Mutharika was referred to Zomba Mental Hospital for a psychiatric evaluation under order from the High Court of Malawi, Criminal Division, Homicide Bail Application Number 130 of 2020, in the matter of Section 42 (2) (e) of the Constitution between Chisale and the State.
Dr. Liwimbi — who has 15 years experience as a medical doctor (MBBS2005) and over 10 years experience working in psychiatry with four of those years as a specialist psychiatrist (MMED Psychiatry 2017) — says the few symptoms Chisale presents with do not meet criteria for any psychiatric disorder.
Or that they are not significant psychiatric symptoms; or are marred with marked inconsistencies; or cannot be validated by objective assessment or were intentionally produced.
Liwimbi said Chisale’s assessment comprised of history and mental state examinations, physical examination, laboratory investigations, nursing observations, collateral information and cognitive testing.
“He gave a history of chest pain on the left, and other times mentioned heart palpitations,” says the doctor. “Associated symptoms were shortness of breath, headache and tremors. He also indicated feeling angry.
“The symptoms are brought on by being around the police, which was later changed to being around more than 10 people.
“During another session he mentioned he did not know the number of people that made him anxious, but wanted to just be left alone. He said he does not sleep and is not aware of the duration.
“He is unable to walk due to painful legs; on being asked how he managesto go to the bathroom he indicated he is able to walk for short distances only.”
Liwimbi went o to report that Chisale did not describe any other symptoms of anxiety nor panic attacks and that did not know how long he had these symptoms for.
“He denied previous symptoms of social anxiety disorder, denied having any phobias and did not know if he had symptoms of general anxiety disorder previously.”
On depressive symptoms, Liwimbi said Chisale claimed to have low mood but can’t remember for how long.
“He said ‘no’ to all other symptoms of depression, including no to suicidal ideation.”
Chisale is reported to claim to hear the voice of Prophet Shadreck Wame preaching “unvarnata ndi usungwana ngwa chabe” and that he also heard music playing throughout the night but the voice/sounds were from within his head.
“He was could not remember any other details of the voices/sounds. On subsequent reviews he claimed to hear the songs anytime but they would stop when he is sleeping.
“He denied having all other psychotic symptoms by saying ‘No’, however he responded with ‘I don’t’ know to questions screening for grandeous delusions and delusions of reference.”
On what is termed as cognitive symptoms, the Doc. said Chisale claimed to not have any memories of his past.
“He responded with ‘I don’t know to most questions’. He claimed to not know his age, or have any recollections of his entire life. He, however knew that he had a wife and his daughter’s name.
“Much history could not be sought as his responses were ‘I don’t know, or ask my wife’. His response was ‘I don’t know’ when asked on screening questions for cognitive impairment.
“He had, however, earlier been able to state that he had been hearing sounds for several days; that he has had headaches for over 10 years on and off — although he couldn’t remember the medications he had taken for it among other things.”
Liwimbi continued to say on the initial interview Chisale claimed to not know if he had peptic ulcers or not. He was informed the analysis needed this information for management to top up paracetamol for his headaches and that such medications are contraindicated for someone with ulcers.
“He was able to state clearly that he doesn’t have peptic ulcers on the second review.
The Doc. said Dr Chiwaula or prison medical services — through a phone conversation had reported that Chisale was brought to the clinic by an inmate with a history of collapse.
He is reported to have ‘fallen’ at the door to the clinic but there was no loss of consciousness and Chiwaula reported that Chisale’s initial blood pressure was elevated with diastolic above 101 and returned to normal on repeat examination.
“He was then sent to a private clinic in the company of his personal doctor on his request. No history of head injury.”
His personal physician Mr. Chiwawa (Diploma clinical medicine), via telephone is said to have treated Chisale for 2 years, saying he has a history of headaches and back pain which is treated routinely with analgesics.
“No other significant medical history. No known psychiatric history,” says the report.
Another medical doctor, William of Polymed clinic (MBBS), via telephone also reported that Chisale had a normal physical examination other than rash.
“His blood pressures remained within the normal range while at the clinic. Investigations were all normal.
His wife reported that he has been healthy with no known medical or psychiatric conditions and has no history of alcohol or any substances.
Mental State Examination
On initial review of appearance and behaviour, Chisale was lying in bed and hesitant to sit because of back pain and on subsequent visits was able to sit up promptly and sit for well over an hour without any complaints or observable signs of pain.
“He had minimal engagement with very little eye contact with gaze shifting from one side to the other more at the beginning and diminishing to very minimally by the end of the sessions.”
He is a said to have initially been grimacing and frowning frequently but this subsided during the course of the initial session and was almost non-existent in subsequent sessions.
Initially, Chisale is said to have been anxious but gradually relaxed as session progressed to being relaxed on all subsequent visits.
“There was NO evidence of formal thought disorder, delusions, or negative symptoms. He described primary hallucinations from within his head.
Regular observations at night showed that Chisale was able to sleep most nights and that on two nights he slept very late at night and also woke up late in the mornings.
“When asleep he does not notice the door being opened nor respond when his name is called softly.”
He is reported to be able to walk without any obvious signs of pain and he is able to sit promptly without signs of pain. He rarely requested for paracetamol, and mostly does so when a doctor was doing an assessment.
When various people came to visit, Chisale was able to chat and they converse clearly without him using phrases like ‘I don’t know’. He is said to have followed up on progress on events that happened while he was in prison and initiates conversations on things that happened in the past.
“When conversing with visitors, there is no evidence of him having memory loss or difficulty paying attention to the conversation. He is able to ask on the money that was left for him on admission, able to ask for groceries that were bought for him and have been kept in the fridge.”
“He declined to have bloods taken for HIV and syphilis. This was despite being informed it is important to test this for screening for memory impairment.
“He, however, accepted to have blood samples taken for the remaining tests and for a call to be made to his wife to arrange for payment at Mwaiwathu hospital.
“He was able to follow this discussion and make a decision without showing any deficits in attention or concentration.”
In his summary, Liwimbi contends that there might be a possibility that Chisale had some symptoms of anxiety while in prison and this is based on the symptoms that were described — chest pain, heart palpitations, feeling afraid that he would die and tremors which are consistent with a panic attack.
“The initial elevation of blood pressure which returned to normal after resting is in keeping with someone who is anxious. Note, however, that Diagnostic and Statistical Manual of Mental Disorders version V, page 217, indicates panic attacks should not be diagnosed if the intense emotion is anger.
“Such would be described as anger attacks. Mr Chisale described being angry during the episode. Also note that anxiety is a normal reaction to stress, and therefore it is understandable that someone in custody may feel anxious.
“The rest of the symptoms that he describes are NOT CONSISTENT with any psychiatric disorder.
a. Psychosis: Primary hallucinations from within the head which he described are not a significant feature of psychosis. There was no objective evidence of him having hallucinating throughout all the assessments. There was no other evidence of psychosis such as delusions or formal thought disorder. While a person may feigh other symptoms of psychosis,it is extremely difficult to feigh formal thought disorder.
b. Depression: Though he claimed to have low mood, he did NOT have any of the other 8 symptoms of depression. A person needs at least five symptoms to meet criteria for depression. Poor sleep is a feature of depression and although he described this, objectively he did NOT have poor sleep objectively during the period of the assessment.
c. Cognitive impairment:
i. Mr Chisale gave a history suggestive of anterograde and retrograde amnesia (loss of past and new memories). This is inconsistent with objective findings during history taking, mental state examination and observed interactions where it was clear he can remember both past and recent things.
ii. He intentionally failed his cognitive tests.
a. MMSE and MaCA scores of 3/30 and 0/30 are consistent with a patient with severe dementia who would be grossly impaired, which is NOT his clinical presentation.
b. He failed simple tasks such as subtracting 7 from hundred serially; repeating 3 words immediately and remembering them. Yet he was able to recall money had been left for him, that he had Coca-Colain the fridge, and could initiate and follow up on matters he discussedwith his spouse while in custody.
c. In true cases of cognitive impairment, a person does not lose the capacity to repeat 3 words, write a sentence, copy diagrams as he demonstrated on cognitive tests, yet still be able to tie buttons, execute complex actions such as unplug a fan from one wall socket and plug it to the nearest to his bed as examples.
d. He made very minimal effort on his tests. Patients with dementia put in effort on the test and fail. The picture where minimal effort occurs is consistent with pseudo- dementia which occurs in severe depression.
Liwimbi contends that Chisale does not have depression and it is one of the areas where he clearly denied having symptoms.
“He gave false information — on most nights he claimed to have poor sleep and that he spends his time lying down with eyes open yet on most night’s hourly nursing observations indicated that he would be asleep, would not notice the door open nor respond to his name being called softly.”
The experienced Dr. Liwimbi says he has managed numerous forensic cases throughout the 10 years experience working in psychiatry and also has experience managing forensic inpatients and conducting forensic assessments for the courts while attached to the Forensic Unit at Valkenberg Hospital in CapeTown, South Africa.