By Dr Ghayur Ayub

In my article of October, 2009 titled, 'Mental health disorder: its legal manipulations,' I wrote “Dementia (meaning "deprived of mind") is part of mental health disorder. It is a serious cognitive condition which is chronic in progression and usually irreversible in nature. It affects areas related to memory, attention, language and problem solving; the outlook of which depends on the cause. For example, dementia caused by vitamin deficiency can lead to full recovery of memory while patients suffering from other causes may not recover completely; such as memory loss caused by stroke may take years to recover. Chronic use of substances such as alcohol can also predispose the patient to cognitive changes suggestive of dementia.”

The article further said, “The term cognition refers to a faculty for the processing of information, applying knowledge and changing preferences. It can be conscious or unconscious and is considered as an abstract property of the living brain at factual and symbolic levels. In psychology, cognition is used to refer to mental functions, thought  processes and state of intelligence, pertaining to comprehension, inference, decision-making, planning and learning. Especially important is the point that ongoing patterns of feeling, thinking and behaviour are said to be caused by underlying belief systems which can enhance what may be a person's egoism therefore, he may see himself appropriate for a job he is not fit for.”

“It is important to note that it requires at least 6 months for the disease to remain before diagnosed as dementia; otherwise the condition is termed delirium. The two can easily be confused because they have common symptoms. The former is chronic which may not be treatable; the latter is acute and is usually treatable. In all types of the former, the higher mental functions such as memory, attention, language, and problem solving are affected first. Later, the affected persons may get disoriented with time (not knowing what day of the week, day of the month, or even what year it is), in place (not knowing where they are), and in person (forgetting the names of close relatives or others around them). Some other mental illnesses such as depression and psychosis, may also produce similar symptoms which must be differentiated from dementia and delirium. Patients who suffer from both depression and dementia often show some improvement in intellectual functioning when the depression is treated.”

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“History tells us that whenever evolution took place in a field, it opened up doors for humans to manipulate it where they deemed fit. Mental health evolution is not an exception. In the race between psychiatrists and psychologists on one hand, and political manipulations on the other, a game field was prepared in which politicians used mental health professionals to obtain political gains through legal cobwebs. In recent decades, I can give three examples from the UK courts; two pertain to British citizens, one to a Pakistani.”

They were Peter Suthcliffe and Michael Fagan from England and Asif Ali Zardari from Pakistan. The article mentioned, “The third case involves, Mr. Asif Ali Zardari, in which mental health disorder was used as legal tool to abstain from court hearings when he was called to appear before a London High Court in March 2007 in relation to the Rockwood Property dispute in Surrey. He produced medical certificate issued by two psychiatrists, Philip Salteil and Stephen Reich from New York State. One psychiatrist wrote, ‘he (Asif hpw Ali Zardari) was suffering from dementia, depression and post-traumatic stress disorder’ making him forget the names of close relatives such as his children. The other psychiatrist confirmed the diagnosis and added that his time in jail ‘left him with severe emotional instability, memory loss and concentration problems. I do not see any improvement in these issues for at least a year’. That certificate was accepted as valid document by the court.”

Vast majority of psychiatrists agree that the condition is chronic but can be triggered by; 1), TIA (Transient Ischaemic Attack); 2), minor stroke; 3) persistent stress. All or either of these three can induce an acute attack with damaging or even disastrous consequences. The patient becomes disillusioned, irrational, aggressive and even abusive. He starts behaving in unmannerly behaviour. In other words he gets out of control. With this background there are a few important questions pertaining to AAZ's recent episode which hit the media;

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1.      Did he ever suffer from dementia? The evidence provided to London High Court proved that he did.

2.      Is it a chronic condition? The medical literature says it is.

3.      Can it revert to 'acute form'? Yes, it can by triggering factors.

4.      Can a patient with acute attack be dangerous to himself and others? Yes he can be. That is why such patients are 'sectioned' by law if they resist/refuse admission.

According to reports, AAZ was under sever stress because of; Supreme Court decision on NRO appeal; revelation of Memo related to May 2nd attack; Hussain Haqqani's resignation; Supreme Court taking swift action on Nawaz Sharif's plea on 'Memogate'; and the Chief Justice in way equated it with 'Watergate' in his remarks. There also had been reports that he either suffered a 'TIA' or a 'Mild Stroke'. Either of these was enough to transgress the critical point and cause an acute attack. According to reports during a meeting with the American Ambassador he exploded and used harsh words. The Ambassador must have reported it to Washington and a few hours later when Obama rang AAZ, he was 'incoherent' and irrational. An important leader of opposition party was the last person to meet AAZ before he was flown to Dubai. According to a reliable source after seeing him in that 'state' the opposition leader rang the PM advising him to send him abroad before his condition is known to the public.

The big question is would he be able to resume his responsibilities as the President of Pakistan and the Supreme Commander of armed forces with his finger on Pak nukes? The indications are that the pressure and so the stress is not going to die down. As a matter of fact it is going to rise in coming weeks and months. Can the increasing pressure induce another similar or worse attack? The psychiatrists would most certainly agree so. In that case, can Article 63 (a) of Pakistan Constitution regarding his disqualification for the post becomes applicable? The article states “he is of unsound mind and has been so declared by a competent court.” When the London Court accepted the certificates as legal documents which diagnosed him to be suffering from dementia (patient with unsound mind), the honourable court actually agreed with the diagnosis. Because of the extreme sensitivity of the condition and tremendous responsibility of the post can a Prima Facie case be made in Supreme Court of Pakistan with argument that at the time of his election this point was not brought to the notice of Election Commission. In common law jurisdictions, prima facie denotes evidence that – unless rebutted – would be sufficient to prove a particular proposition or fact.