Menuck Report

Consultation Note of Dr. M. Menuch of February 27, 1998

CONSULTATION NOTE

Dr. M. Menuck

February 27, 1998

REASON FOR CONSULTATION: Review of management

Dear Doctor Mantle:

In May and June 1997 this 41year old man was found mentally unfit to stand trial on charges of sexual assault and breach of a condition of an undertaking. He was detained on those charges in St. Thomas Psychiatric Hospital between June 1997 and January 1998. Following a hearing by the Ontario Review Board on December 22, 1997, he was transferred from St. Thomas Psychiatric Hospital to Penetanguishene Mental Health Centre. Oak Ridge Division. On January 20 1998, he was admitted to The Forensic Assessment Program. At the time of admission, you noted That Dr Verma was anxious and did not communicate with you except with crayons and signs. I understand that since that time he has Communicated in the same manner, occasionally uttering 'Yes' or 'Yup' in response to questions but otherwise relying on signs, written letters and words, and drawings. Evidently he is able at least sometimes to comprehend spoken questions and instructions, since on some occasions he has been observed to nod his head appropriately and gives other nonverbal indications that he has understood oral communications. You have advised me that he prefers to communicate through written or printed messages directed to him in the form of notes, or by pointing to letters that spell out words, and he responds by using the same techniques. He has made a number of requests in that manner, and has presented no significant management problem except for the time demands imposed by this laborious method of communicating. On February 18, he shoved a staff member in anger and was secluded. On February 20, he spelled out to his nurse “I was strangled and raped in jail and have a 10 minion dollar lawsuit against the jail." According lo the nurse, he smiled and gave a thumbs-up sign before walking away.

I found the following background information in Dr. Verma's hospital file:

Dr. Verma was born and raised in India. No detail about his birth and early development are documented in the file. By his own account, his father was an accounting clerk and his mother was a teacher. He has described his father as a very angry man who physically abused his sons. I understand that his parents reside British Columbia and a younger brother practises medicine in New York. According to records from St. Thomas Psychiatric Hospital, while he was detailed in that hospital, Dr. Verma complained to police that his father and brother were harming him, and advised his mother to divorce his father. No other relevant family history is documented.

Dr. Verma has reported that he was bullied by other children because they envied his cleverness and academic excellence. By his father’s account, his problems with other children arose from his need to appear intelligent and later he had similar difficulties white attending medical school where his arrogant behaviour alienated his teachers. I understand that he came to Canada in 1983, and a few months later he married his current wife in British Columbia. I believe that marriage was arranged by their families while he was a medical student in India and she was training as a nurse in British Columbia. They have three children ranging in age from approximately 5 to 11 years. According to his father, Dr. Verma domineered and severely restricted his wife. In 1996, they separated and she moved with the children to her parents' home in British Columbia. 1 understand that following the separation he was charged with criminal harassment and was released on condition that he would not associate or communicate with his wife and children, I also understand that sometime later in the same year, his wife and children moved back to Ontario and lived with Dr Verma in Kitchener. His wife worked as his medical secretary al that time. In November 1996, while investigating the charges of sexual assault, police learned that Dr. Verma was living with his wife and children and he was charged with failing to comply with the undertaking not associate or communicate with his wife and children.

By all available accounts, Dr. Verma excelled in his medical studies and successfully completed his medical training in India before emigrating to Canada. Later he enrolled in speciality programs in internal medicine and in Neurology, studying for periods of time in British Columbia, Alberta, Saskatchewan and Manitoba. I understand that despite his diligent work in those studies, Dr. Verma encountered a number of professional setbacks.

In or around 1989 (?) Dr. Verma sat in the examinations in the Royal Colleges or Physicians and Surgeons of Canada, and American Board of Psychiatry & Neurology. He passed the written examinations in neurology but was unsuccessful in tne oral examinations. Later Dr. Verma told his physician in Kitchener that one of his supervisors considered him incompetent and engineered his failure on the oral examination by including the examiners.

After failing the examination, Dr. Verma was unable to obtain a medical practitioner’s license in British Colombia and practised general medicine for a period of time in Ontario. Later he retuned to British Columbia and received a medical licence in that Province which was subsequently revoked on grounds of disgraceful conduct and moral turpitude. Dr. Verma told his physician in Kitchener that afler he pressured the Colleges cf Physicians a Surgeons to grant him a license, they put him under a microscopy, looking for a pretext to revoke his licence.

I understand that after losing his medical license in 1993, Dr. Verma practised general medicine in Toronto and Mississauga and finally in the Kitchener-Waterloo area where the charges of sexual assault arose in 1994 and 1995.

The records from St. Thomas Psychiatric Hospital and Royal Ottawa Hospital indicate that, during the course of those professional setbacks, Dr. Verma began showing signs of medical and/or psychiatric disturbances, which have continued and progressed until this time.

In 1993, Dr. Verma was an inpatient in University Hospital in Vancouver for two weeks. He was complaining of right-sided headaches and neuromuscular problems that interfered with writing and shaving himself. Examinations and investigations, including CT examination disclosed no medical explanation for his symptoms. Final diagnoses were major depressive disorder, alcohol abuse, conversion disorder and narcissistic personality traits. Verma was discharged on Nortryptyline and Clonazepam, with recommendations for cognitive behavioural and marital Therapies. No other details about his psychiatric problems or the psychiatric care he received are documented in. the file. No records from University Hospital are included in the file.

In 1993 or 1994, Dr. Verma was practising medicine in Toronto far a period of time. Later he told a psychiatrist in Kitchener that a medical colleague in Toronto reported to Ontario College of Physicians & Surgeons that Dr. Verma was mentally unbalanced. The psychiatrist has indicated that as a result of that allegation, Dr Verma was examined by Dr. Collins in February 1996, and by Dr. Lesser around the same time, and neither psychiatrist found evidence of mental disorder at that time. No reports from or Collins and Dr. Lesser are included in the file.

Dr. Verma's wife has reported that in 1994, while he was establishing a medical practice in Kitchener, he showed signs at memory impairment and his speech was slow.

The hospital records indicate that, in his written correspondence with his estranged wife in 1996, Dr. Verma enclosed news clippings describing a brutal domestic murder that occurred in Vernon B.C. As a result of that alleged behaviour, he was charged' with criminal harassment and was released on condition that he would not associate or communicate with his wife and children.

Dr. Verma's wife has reported that in 1996 he engaged in reckless spending, made business plans that might have reflected impaired judgement, contacted people by telephone in the middle of the night, and embarrassed his children by appearing in public in his dressing gown.

In May 1596, after the charger of sexual assault arose and his wife left him, Dr. Verma disappeared for a few days. Later he explained that he went away to think. His mother took him to Kitchener-Waterloo Health Centre where he was admitted with suicidal thoughts and inability to cope with the stress of court proceedings and marital breakdown. During the 5-day hospital slay he showed no evidence of depression or suicidal risk. He was described as seeking attention, uncooperative with hospital rules, demanding and threatening. He complained to the Medical Director before signing himself out of hospital. His psychiatrist felt that he displayed evidence of many personality problems. Later Dr. Verma was examined as an outpatient by Dr. Heath. He told Dr. Heath that before arriving in hospital he was considering suicide by cutting an artery, swallowing poison or crashing his car, and had faxed a letter to his wife's lawyer making what sounds like a suicide threat. He suggested that Dr. Hearh should engineer his wife's return by giving her false medical information and indicating that Dr Verma’s recovery depended on his wife’s presence and support. Dr. Health noted signs of anxiety or depression, and offered a diagnosis of adjustment disorder associated with unspecified personality disorder.

In June 1996, Dr Verma was readmitted to Kitchener-Waterloo Health Centre with suicidal thoughts. His mother had recently returned 1o BC and he fell unable to cope He showed no evidence of depression or psychosis, and after one month he was discharged with follow-up by Dr. Surapaneni.

Sometime in 1996, Dr. Verma was admitted lo Cambridge-Waterloo Regional Detention Centre. According to records from Royal Ottawa Hospital, he was detained in Cambridge -Waterloo Regional Detention Centre a1 least twice on drug charges and on those occasions, he acted normally. No details concerning those oftenses are described in the file.

I understand that Dr. Verma was re-admitted to Cambridge-Waterloo Regional Detention Centre on November 27, 1996.

An admission note includes some historical data. This may indicate that Dr. Verma was verbally responsive to questions at that time.

An undated medical note, evidently written by the jail physician on or around the date of admission, described Dr. Verma as, "nonverbal” and somewhat un-cooperative during examination. The physician noted a tender swelling on the bridge of Dr. Verma’s nose, left peri-orbital bruising, and no gross neurological abnormalities.

Another note written on December 1, appears to describe the onset to the language abnormalities and other odd behaviours that Dr. Verma currently exhibits. According to the note Dr. Verma was observed lying on a bench with dried blood on his face from a nosebleed and exhibiting a slight swelling over the left supraorbital area. His pupils responded very slowly to light and he moved his limbs very slowly.

Initially he appeared dazed and answered only "Yes" to questions. Later he became verbally unresponsive, responded only to painful stimuli, was incontinent and drooling, and his respirations became irregular and deep. He was transferred lo Cambridge Memorial Hospital. Upon his return he was again answering "Yes" to questions and was unresponsive to directions. A nurse observed that his right arm and foot seemed weak and he still complained of tenderness over his left forehead.

On December 3, Dr. Verma was described as verbally unresponsive except for the "Yes yes" utterances, and staring with an emotionless bewildered expression as if hallucinating, Catatonic schizophrenia was considered as a diagnosis.

On December 10, Dr. Verma was still answering, "Yes yes”, and was also tapping out indecipherable answers on the table and drawing pictures to indicate his needs. The next day, he was transported to Brantford General Hospital for CT examination but he refused to cooperate with the procedure.

According to other information in the hospital file, while he was incarcerated in Cambridge-Waterloo Regional Detention Centre, Dr. Verma alleged that another inmate had beaten him. He removed his personal belongings from the cell and flushed other materials down the toilet. There was evidence of minor head and facial injuries. He looked confused, responded slowly and inappropriately to questions, and answered every question with a faint “Yes". He defecated in the floor in full view of staff members in the emergency department at Cambridge Memorial Hospital, defecated in a parking lot beside a jail van while observed by jail personnel, and was observed lying in his own urine and excrement in Jail.

On December 16, 1996, Dr. Grancy examined Dr. Verma in jail. He found that Dr. Verma answered “Yes" indiscriminately to every question, typed on an imaginary keyboard on the table, and drew irrelevant sketches in response to directions. He also communicated in gestures that were more meaningful -For example; he pounded his head to indicate that he had been beaten. Dr Glancy suggested diagnoses of ‘Ganser Syndrome’, ‘Brief Reactive Psychosis’ or ‘Subdural Haematoma after head injury’, and recommended that Dr. Verma should be remanded to Royal Ottawa Hospital for fitness evaluation.

Dr. Verma was detained in Royal Ottawa Hospital from December 1996 to February 1997.

EEG and Chest X-ray in December 1996 were normal. Brain MRI in January 1997 was normal.

In December 1996, Dr. Verma was examined on two occasions in the emergency department at Ottawa Civic Hospital. I understand mat he complained of chest pains and collapsed, but no medical abnormally was detected. EKG examinations were normal. No records from the hospital are included in the file.

In. December' 1996 Dr. Kunjukrishnan examined Dr. Verma. He noted that Dr. Verma

· appeared to comprehend spoken English although he replied "Yes" to every question and otherwise communicated via gestures and drawings.

· described headache by gesturing

· demonstrated repeated violent coughing and appropriately requested some cough syrup by drawing a picture of dunking glass

Dr. Kunjukrishnan considered diagnoses of catatonic schizophrenia, dissociative state with hysterical aphonia, and factitious disorder.

In January 1997. Dr. Lapierre examined Dr. Verma with the assistance of a Punjabi interpreter. He noted that Dr. Verma

· comprehended spoken English, replied 'Yes" appropriately but not coherently, and typed coherent answers in Punjabi

· described visual loss in the right field, right hemiplegia, and inability to write in Punjabi or type in English

· reported that he may have experienced three recent seizures, and was raped six times and almost strangled

· demonstrated right sided peripheral vision loss and hemiplegia

Dr. Lapierre considered the possibility of neurological disease resulting in subcortical motor aphasia, and interpreted Dr. Verma's statements about being raped and strangled as possible evidence of paranoid psychosis,

In January 1997, Dr. Koranyi also examined Dr. Verma. He noted that Dr. Verma

· comprehended spoken English, replied "Yes" appropriately and otherwise communicated his answers in gestures and drawings

· described right-sided headache, buzzing in his ears, chest pain radiating to the left arm, vomiting and cough, and poor sleep

· reported that he experienced two recent seizures and fainting spells, and staled that he was beaten, strangled and raped 6 times in jail.

· demonstrated no gross sensorimotor impairments but was unable to associate printed labels to objects that were shown to him

Dr. Koranyi felt that Dr. Verma's comprehension ruled out Wernicke's and Broca's aphasias, transcortical sensory aphasia, amnestic aphasia, ideational motor apraxia, asymbolia, and Gerstrnann's syndrome, he suggested diagnoses of hysterical aphasia and malingering.

Around the same time, a forensic social worker noted that Dr. Verma comprehended questions in spoken English and responded by pointing to clippings that depicted what he wanted the questioner to know, saying "Yes, yes" when the questioner guessed the correct answer. He indicated by gestures that he understood the interviewer's questions He also made spontaneous comments by gesturing. The social worker compared the interview process to a game of charades. He observed that later Dr. Verma appeared lo tie eavesdropping while the interviewer was sharing information with nurses on the ward. He also reported that, according to another patient, Dr. Verma was able to address the patient by his first name.

In February 1997, Dr Krelina examined Dr. Verma. he noted that Dr. Verma

· appeared nor to comprehend spoken English since he replied "Yes' lo every Question regardless of content, although he appeared to understand some typed questions

· described headache by gesturing to his head and grimacing

· demonstrated left hand tremor, facial asymmetry with evidence of right sided (facial muscle weakness, possible right sided hemiplegia, artificially elevated blood pressure (by performing a Valsalva maneuver) and signs of anxiety

Dr Krelina concluded that subcortical vascular and demyelinating diseases were remote possibilities that might be ruled out by CSF and evoked potential studies. He suggested that Dr. Verma was demonstrating evidence of factitious disorder that was triggered by narcissistic injury following loss of prestige and family. He added that some of Dr. Verma's complaints and disabilities seemed to be consciously motivated by fear of imprisonment.

Despite Ifie rmparred behaviours (that Dr .Verma exhibited in Royal Ottawa Hospital, he functioned quite well in some activities. He was able to play chess and table tennis, and paid attention while watching movies. He was able to use a typewriter to communicate coherently in Punjabi and later in English, I understand that at some. point during his stay in Royal Ottawa' Hospital Dr. Verma's behaviour became problematic. He deliberately poured coffee on the floor, and on two occasions, he was uncontrollably violent.

In February 1997, Dr. Bradford and Dr. Greenberg reviewed Dr. Verma’s history. They noted that the nature of Dr Verma's alleged sexual offences against female patients was unusual and might [if confirmed] reflect sexual disinhibition as a result of mental disorder. They found no evidence for neurological disorder. In their opinion, Dr. Verma demonstrated clearly that be was cognitively unimpaired and able to comprehend and communicate complex concepts, and showed no evidence of anxiety, depression or psychosis. They suggested diagnoses of factitious disorder or malingering. They felt he was mentally fit to stand trial.

On February 13, 1997, Dr. Verma was returned to Cambridge Waterloo Regional Detention Centre. He continued to communicate in monosyllables, drawings and hand gestures. Often his communications were about physical discomfort in his head, chest and abdomen.

On February 17, Dr. Glancy reassessed Dr. Verma in Jail. He found that Dr. Verma still answered “Yes" and rnade stereotyped gestures in response to most questions. however he had acquired the use of a laptop computer and was able to type appropriate replies to some questions.

On March 7, Dr. Verma was examined by a psychiatrist in Cambridge Waterloo Regional Detention Centre. He answered "Yes” inappropriately to every question. The psychiatrist made a diagnosis of probable schizophrenia and prescribed Loxapine 25 mg and Clonazepam 1.0 mg daily and Dr. Verma evidently accepted those drugs.

On March 14, Dr. Verma remained verbally unresponsive but he nodded his head appropriately and was observed reading his medical file. The medications were changed to Loxapine 25 mg and Diazepam 20 mg daily.

On April 1, Dr. Verma was replying "Yeah" to all questions. The medications were increased ro Loxapine 50 mg and Diazepam 20 mg daily. On April 4, the psychiatrist changed the diagnosis to elective mutism.

On April 11, the medications were discontinued as ineffective.

On April 18, Dr. Verma was asked to write his name and produced a meaningless scrawl. He responded to questions with "Yeah" and with gestures. The psychiatrist felt unable to exclude malingering.

On May 16 Dr. Verma was asked how he was feeling and answered "'OK.” In other respects, his appearance and behaviour were unchanged.

In April 1997, Dr Verma was remanded to METFORS but we have no records from that facility. Dr. Glancy examined him again on April 28, and found that Dr. Verma was no longer typing comprehensible answers on the computer, answered "Yes” to every question, and looked perplexed and bewildered. He showed a marked tremor. Dr Glancy again suggested a diagnoses dissociative disorder (or Ganser's Syndrome) and conversion disorder with motor symptoms (or hysterical aphonia) He accepted to proposition that those disorders were triggered by physical or sexual assault, and perpetuated by his fear of retuning to jail and possibly being attacked again, and felt that under the circumstances Dr. Verma was not mentally fit to stand trial.

On May 6, 1997, Dr. Verma was found mentally unfit to stand trial on 2 charges of sexual assault He was remanded to St. Thomas Psychiatric hospital where he was detained from June 1997 until January 1998.

At the time of admission, he was noted to be very anxious, guarded and preoccupied with somatic discomforts He communicated by typing on a computer keyboard, insisting that the questions as well as his answers must be typed. He also drew diagrams to describe his chest and head complaints. After 10 minutes, he ended the interview. Provisional diagnosis was factitious disorder with anxiety.

On June 16, Dr Verma returned to court and was found mentally unfit to stand trial on a 3^rd charge of sexual assault and the charge of breach of a condition of an undertaking, he was returned to St. Thomas Psychiatric Hospital at that time.

Psychological testing in July 1997 suggested mixed personality disorder, mixed paraphilia, and malingering. The psychometerist noted covert resistance to testing and interpreted some or the test data as invalid. He reported that Dr. Verma described vague auditory, visual and sensory abnormalities, and alleged: that police laid false charges against him and plotted to harm him. In September 1997, indirect laryringoscapy revealed normal vocal cords. Around the same time Dr. Verma typed a letter to hospital personnel, stating in part "1 do not understand any verbal input, which makes me deaf for practical purposes, I do hear the sounds and turn my head to that. This confuses people it is a special neurological syndrome of word deafness type. I can understand music but not spoken words. I cannot write either. But I can effectively communicate using a computer or typewriter.1 can read only printed material. Cursive writing is also a problem. When I am having visual hallucinations I understand only a few words and may misunderstand. Therefore, you have to bear with me. With my sensory hallucinations, I make tones [sic] of spelling mistakes ar type gibberish” around the same time he requested closed captioning on television programs.

In October 1997, Dr. Verma was examined in a speech pathology clinic. He complained of inability to talk or write, understand spoken words, understand handwritten words, or understand his own speech. He also described auditory hallucinations that interfered with his comprehension. Evidently, he diagnosed the origin of those symptoms and dysfunctions as conversion aphonia as component of Ganser's syndrome, and requested the use of a computer or skills training in lip-reading and ASL. Personnel from St. Thomas Psychiatric Hospital reported overhearing Dr. Verma conversing with other patients despite his claims of speech impairment, and observing him watch television and read newspapers despite his descriptions of impaired speech and verbal comprehension. The speech pathologist noted normal vocalization, which was limited to monosyllables (e.g., “Yes”) and vegetative voicing (i.e. coughing, throat clearing), and suggested that Dr. Verma’s problems were broader than conversion aphonia and were not amenable to treatment by a speech pathologist. Around the same time, Dr. Verma began requesting therapy for Ganser's syndrome. He agreed to that of Loraepam but quickly changed his mind. He refused treatments with antidepressant and antipsychotic drugs, and refused abreactive drug therapy.

Audiological testing was conducted in September and October 1997. Initial data, which were considered unreliable, suggested the possibility of moderately severe asymmetric hearing loss. Subsequent testing indicated normal hearing or possibly mild-to-borderline hearing impairment bilaterally.

In October 1997, a female patient alleged that Dr Verma had assaulted her sexually. He professed his love for her and a desire to form a long-term relationship with her.

In November 1997, Dr. Verma was observed giving proscribed food to a diabetic patient. He became agitated when confronted and required restraining. Around that time the treatment team in St. Thomas Psychiatric Hospital recommenced that Dr. Verma was posing unacceptable risks to patients in that hospital and should be transferred to Oak Ridge Division.

In December 1997, Dr. Merskey reviewed the case and offered a diagnostic opinion. Dr. Merskey had access to copies of records from University Hospital in Vancouver, court documents from both the Provincial and Supreme Courts of British Columbia, statements from the alleged victims of sexual assault by Dr Verma, reports from Drs. Collins and Glancy, and consultation notes and laboratory reports from Royal Ottawa Hospital. He was unable to elicit any speech from Dr. Verma except the word "Yes", but he read typewritten statements that of. Verma prepared in advance and provided to him. He noted that Dr. Verma was unable to type coherent messages in his presence. Dr. Merskey concluded that Dr. Verma was demonstrating an ability to communicate that was incompatible with any morbid condition except malingering. He also noted the likelihood that Dr. Verma was depressed and might benefit from antidepressant medication.

In January, 1997 Dr. Verma was transferred to Oak Ridge Division with a final diagnosis of malingering and possible depression.

On February 16 Dr. Verma, preparing for sexual preference assessment by the Research Department, indicated by handprinted, notes that he was unable to understand the spoken instructions that he was given, and by letter chart that he was unable lo understand printed words either. The interviewer observed that just before their meeting Dr. Verma appeared to respond appropriately to Dr. Gardiner's spoken instruction, and a short time later he appeared to be reading printed material without difficulty. Because of communication, problems the he sexual assessments were not conducted.

I have no particular skills that would enable me lo evaluate Dr Verma's problems by personal examination. Therefore I will rely on the compiled record' to state my opinions and make my recommendations.

OPINIONS AND RECOMMENDATIONS:

1. This man's history and presentation raise very hard questions. We should approach them armed with the best and most complete background history we can obtain. It would be most helpful to get any records that are available in METEORS and Hamilton Wentworth Detention Centre, psychiatric reports from Dr. Collins, Dr. Lesser and Dr. Surepaneni, and information from Dr. Verma's, wife and brother who might be able to add reliable and firsthand observations about his upbringing, habits and personality.

2. Dr. Verma's father and wife describe him as an intelligent and industrious Individual, but also a very difficult man with traits of arrogance and rigidity. His psychiatrist in British Columbia commented on Dr. Verma's narcissistic traits. Dr. Verma’s repeated failures in oral examinations, in a field of study that he pursued diligently and in which he mastered the subject niatter sufficiently to succeed in. written examinations, might indicate that he has exhibited difficulties presenting himself and communicating in a manner that would he expected of someone in his position. On the basis of that incomplete information, it would appear that, notwithstanding his high intelligence and motivation to excel, this man has been unsuccessful in reaching his personal, and professional goals primarily because of serious personality deficits. This impression is supported by court documents from British Columbia that describe a pattern of wilful misconduct that is extraordinary in its nature and degree for a man of Dr. Verma's background and training, and would seem consistent with highly self-defeating attitudes and behaviours arising from personality disturbance. The impression is consistent also with some of the behavioural problems that Dr. Verma has presented since his arrest in 1996. Although we lack many details about Dr. Verma's interactions and relationships before his arrest in 1996, the information that is documented in his file is certainly consistent with narcissistic personality traits or narcissistic personality disorder. Furthermore, the elements of criminality and callous explointiveness that established in the matters related to the revocation of Dr. Verma's medical license, if not in relation to the sexual crimes that were alleged later, raises the possibility of additional antisocial traits. Dr. Verma’s most recent behaviours, such as his proposal that Dr. Heath should falsify medical information in order to manipulate Mrs Verma, and possibly his recent exchange with a nurse concerning a muli-million dollar lawsuit, would support an element of antisociality in this man. The mixture or antisocial and narcissistic traits in a severe personality disorders is sometimes called malignant narcissism.

3. In 1393, after Dr. Verma's medical license was revoked, he received treatment for major depression. During the following year his wife noted that his speech and memory were sometimes impaired, and in 1996 she observed that he was spending recklessly, making unrealistic business plans, and acting impulsively by making late night telephone calls and wandering out in his nightclothes. Furthermore, a medical practitioner in Toronto who had opportunities to observe Dr Verma's conduct evidently considered him mentally unstable to such a degree that he filed a report with the Ontario College of Physicians & Surgeons. It seems likely to me that, even taking into consideration that Dr. Verma may have significant personality problems, those deviant behaviours are part of a pattern of bipolar disorder. This leaves open the possibility that Dr. Verma's actions that led to charges of sexual assaults in 1994 and 1995, and criminal harassment rn 1996, were at least partly consequences of mood disturbances affecting his Judgement and behaviour.

4. In 1993 Dr. Verma's psychiatrist mentioned alcohol abuse as another problem. Furthermore, records from Royal Ottawa Hospital indicate that sometime between 1994 and 1996 Dr. Verma was detained on criminal charges in Cambridge Waterloo Regional Detention Centre; I saw no records indicating that he was arrested for illicitly providing drugs so I surmise that he may have been using them himself. Other records state repeatedly that Dr. Verma has not abused alcohol of drugs, in the past. It would be important to get reliable information about his alcohol and drug habits, since they could be relevant to the deviant and criminal behaviours that he has demonstrated. I would expect that professional and personal setbacks would injure this man's narcissistic sensitivities, and in those circumstances, he might abuse alcohol and drugs with consequences potentially very damaging to himself. Perhaps his wife can provide details specifically about his use of alcohol and drugs during the years of their marriage.

5. In 1993, Dr. Verma complained of right-sided headaches, and neuromuscular problems that were not explained by neurological findings. In 1996, shortly after his arrival in Cambridge-Waterloo Regional Detention Centre, his head and face showed signs of recent trauma and he displayed evidence of gross neurological abnormalities such as sluggish pupils and limb movements progressing to semicoma, incontinence and drooling. Since that acute episode he has complained repeatedly about various somatic pains and discomforts. At Royal Ottawa Hospital, he described right-sided headache, right hemiplegia and visual loss in the right field, buzzing in his ears, seizures, fainting spells, chest pain radiating to the left arm, vomiting and cough. Medical examinations at Royal Ottawa Hospital disclosed signs of facial asymmetry, right-sided weakness of facial and limb muscles, right-sided peripheral vision loss and right-sided muscle weakness. Non-neurological examinations were negative; for example, an EKG was normal after he collapsed with angina symptoms. Furthermore, Dr Verma was observed to be very anxious and tremulous, and on one occasions he was caught evidently trying to elevate his blood pressure artifactually. It has been suggested that he exaggerates physical discomforts for emotional reasons. In Vancouver, his anxiousness and unexplained neurological complaints resulted in a diagnosis of conversion disorder. Dr. Glancy offered diagnoses of factitious disorder, conversion disorder and/or dissociative disorder. Later some of the experts at Royal Ottawa hospital accepted those diagnoses and added malingering as an alternative explanation. A reasonable inference is that Dr. Verma's expert training in neurology may have allowed him to incorporate pseudo-neurological symptoms and signs into a psychogenic or malingered clinical presentation. It is even conceivable that he battered his own head and face in jail before falsely reporting that he was attacked by another inmate. I find it difficult to discount the objective findings of right-sided neurological abnormality that were reported at Royal Ottawa hospital, and to exclude the possibility that genuine head Trauma has produced genuine neurological sequelae.

6. A short time after the appearance of injures to Dr. Verma's head and face in December 1996, he began displaying grossly deviant behaviours such as defecating in public and lying in his own urine and excrement he also seemed to be attending to auditory or visual hallucinations. A jail physician diagnosed catatonic schizophrenia and later Dr. Kunjukrishnan considered the same diagnosis. At Royal Ottawa Hospital Dr. Lapierre accepted Dr. Verma's statements about being attacked, raped and strangled in jail as possible evidence of paranoid psychosis. Subsequently, Dr. Verma received antipsychotic drug treatments and, according to the jail records that are available, he did not afterward exhibit bizarre behaviours or other signs of psychotic disturbance (although he occasionally made reference to visual hallucinations that were not reflected in his behaviours as they were earlier). Since his communication problems and somatic complaints persisted, which seemed to indicate that he was not benefiting from treatment, the drugs were discontinued. It is possible to regard the bizarre behaviours, distraction and hallucinations as evidence of malingering 1t is just as reasonable to consider that Dr. Verma may have sustained head injuries that produced, in addition lo neurological changes as outlined, the forms of mental and behavioural disorganization that were observed in jail and al Royal Ottawa Hospital. Such a transient psychosis may have reflected post-traumatic delirium, catatonia or (assuming that attacks he described were delusional in origin) paranoia, or brief psychotic disorder or factitious pseudopsychosis in response to the stress of incarceration. Any of those psychoses may have resolved in response to treatment with neuroleptic drugs or with the passage of time.

7. Coincident with the head and face injuries in December 1996, Dr. Verma's speech and communications became very disturbed the disturbances have appeared to include elements of faulty speech (mutism), faulty comprehension of spoken and written words (auditory verbal agnosia or '”word deafness", and alexia), and faulty written word and sentence production (agraphia). The elements of these disturbances have been mixed, variable and inconsistent. Laryngoscopy and Audiology have been non-contributory.

According to the hospital and Jail records comprised since the beginning of December 1996, Dr. Verma has indicated that

· generally, he is able to comprehend both spoken and written statements, questions and instructions as indicated by his appropriate responses to oral instructions and inquiries, and by his observed ability lo read printed material.

· sometimes, he can understand no spoken communications but is able to read written or typed communications or expressions that are spelled out on a letter board

· occasionally he may be unable to understand both spoken and written communications (i.e. combined verbal agnosia and alexia) as indicated by his indiscriminate and inappropriate 'Yes' answers, and by his inability lo comprehend instructions during sexual preference testing.

· on at least one occasion, he appeared unable to match printed labels to objects that were shown to him.

· on another occasion, he stated that he was unable to comprehend hrs own speech.

According lo the same records, during that at time he has demonstrated evidence of

· virtual mutism with only occasional vocalizations (‘vegetative voicing’ such as grunting, coughing etc.) and isolated words (such as "Yes”, "Yeah", “Yes-yes”, and “OK")

· occasionally an ability to use words appropriately, as when he reportedly addressed another patient by his first name at Royal Ottawa Hospital, and when he reportedly conversed with other patients at St. Thomas Psychiatric Hospital.

· ability to use non-spoken communications (gestures, drawings, handwriting and wordy documents produced on a laptop computer), often very fluently and appropriately (as seen, far example, in the voluminous communications he produced in St. Thomas Psychiatric Hospital), and occasionally in an idiosyncratic manner such as when he replied to questions spoken in English by typing coherent answers in Punjabi), or incomprehensibly (such as when he wrote his name in a meaningless scrawl)

· no signs of incapacity to perform nonverbal activities that are intellectually and motorically challenging, such as playing chess and table tennis, or watching television (or at least the nonverbal content of television programs?)

I understand that grossly impaired language comprehension and production, with combinations of verbal agnosia, alexia and agraphia, can result from impaired perfusion from the left middle cerebral artery Furthermore left-sided cerebral damage, including left middle cerebral arterial damage, is consistent with the various right-sided neurological findings that are described in the jail and hospital records we nave received I am not competent to Judge whether the neurological data that I has been compiled since 1996 (such as the negative findings on MRI examinations), in combination with the clinical observations that have been recorded during that time (including the observed variability and inconsistency in speech and language) are sufficient to rule out intracranial pathology that would otherwise explain Dr. Verma's apparent deficits. I am aware that the more familiar designations (such as Broca's and Wernicke's aphasias) do not accurately describe all the complexities and permutations of language disturbances that are found in clinical practice, and hence an uncommon presentation that fails to conform to one of those syndromes does not exclude bona fide disease. I strongly recommend that Dr. Unsal should be consulted about the likelihood that further investigations, such as PET scan, QEEG and/or evoked potential studies, might help us to either identify intra-cranial pathology or rule it out.

8. If a cerebral origin of Dr. Verma's speech and language disturbances can be excluded, we can consider the possibility that he is purposely feigning illness in order to (a) receive support and treatment i.e.. he is manifesting factitious disorder or (b) avoid incarceration and the consequences of his alleged crimes (i.e. he is malingering). On either basis, we could explain many of his problems as falling into the categories of pseudo psychotic symptoms (such as feigned hallucinatory experiences and pretended beliefs about being attached and persecuted), pseudoneurological complaints (such as fabricated inability to speak, write or understand verbal communications, and walk steadily, as well as falsely reporting heartache, buzzing in his ears, seizures, fainting spells, visual impairments and muscle weaknesses), and other pseudo-somatic problems (including faked chest pain, vomiting and cough). Factitious mental or medical disorder and malingering are both characterized by (1) atypical and sometimes excessively detailed presentation that does not conform to an identifiable illness, (2) fluctuating clinical course, often with symptoms or behaviours that are present only when the patient is being observed, (3) uncooperativeness with examinations and argumentiveness with doctors and nurses, and (4) obvious benefit derived from appearing to be sick and/or impaired. Each of those Characteristics is prominent in Dr. Verma's presentation. However it seems to me that a man with Dr. Verma's advanced medical training and specialized neurological knowledge would, if he were motivated for any reason to feign medical illness, be able to mimic the condition without the gaps and contradictions that are evident in Dr. Verma’s clinical picture. Furthermore, an intelligent man like Dr. Verma will understand that feigning medical illness can only delay criminal proceedings at a cost of being incarcerated in a psychiatric facility, and will not eliminate them or exculpate him in these circumstances.

9. Ganser's Syndrome has been suggested as a diagnosis. Authorities have conceptualized Ganser’s Syndrome in different ways. Sometimes it has been regarded as a feigned illness, the psychological variant of factitious disorder alongside Munchaüssen's Syndrome representing the somatic variant. Approximate answers, which comprise the cardinal feature of the syndrome described by Ganser, are cited as evidence of factitious disorder in DSM IV. For some reason DSM IV also cites approximate answers as evidence of dissociative disorder and refers explicitly to Ganser's Syndrome in that context. When Dr. Glancy suggested Ganser’s Syndrome in this case, he also mentioned dissociative disorder. I find it hard lo understand Dr. Verma's problems as dissociative phenomena. Ganser himself actually viewed the syndrome, which included clouded consciousness, transient hallucinations and sensory conversion symptoms, as a hysterical neurosis. Some experts continue to categorize the syndrome as a hysterical pseudo-dementia.

I think the syndrome by any designation adds little to our understanding of Dr. Verma's problems and is best left out of the differential diagnosis.

10. Some elements of Dr. Verma’s presentation are consistent with mixed conversion disorder. As you know, symptoms of conversion disorders are triggered by environmental stressors and are not purposely fabricated (as in factitious disorder or malingering). The symptoms are often pseudo-neurological in quality and sometimes include psuedo-halluciations in multiple modalities. It can be exceedingly difficult to make a diagnosis of conversion disorder, since the diagnosis requires the exclusion of medical explanations. The nature of Dr. Verma’s symptoms and history make it virtually impossible to exclude intracranial abnormality as a cause of his problems at this time. Furthermore, as I Have stated already, a man with his educational background, if motivated (even unconsciously) to simulate being medically ill, would probably be capable of producing a more convincing simulation that this.

11. In summary, in my opinion we should.

· obtain as much additional background information as possible

· make every effort to clarify Dr. Verma’s neurological status before excluding medical explanations for his speech and communication problems and his various somatic complaints

· consider the possibility that Dr. Verma suffers from, in addition to any medical condition that may be present, bipolar mood disorder, severe personality disorder, and/or substance use disorder, and any of those conditions might be relevant to his present mental state and also the crimes that he has allegedly committed

· only with caution, conclude that Dr. Verma’s complaints and apparent disabilities are products of malingering, factitious disorder or conversion disorder, in order not to overlook medical conditions that might benefit from treatment.

12. I will review additional materials and laboratory data as they become available.

Morton Menuck MD FRCPC

Consulting Psychiatrist. Oak Ridge Division, Penetanguishene Mental Health Centre.

Staff Psychiatrist, Forensic Psychiatry Division, Clarke institute of Psychiatry.