2.1 Diagnostic Procedure

2.1.1

Testing

When making a diagnosis of substance dependence there is no specific test that gives us a clear defined result. Rather sensible use of diagnostic criteria requires some interpolation and judgment, taking into consideration the overall problem, as highlighted by Wesson, DR, Smith, DE. & Ling, W. in their discussion on Benzodiazepine and other sedative hypnotic addiction in (Principles of addiction medicine third edition). For this reason we have guidelines which assist us in determining a dependence diagnosis.

2.1.2

Basis Used for Diagnosis

The diagnosis that was arrived at in Wayne’s case was based upon the following:

1. The Overall Clinical Picture
2. The History - the documents and letters that Wayne supplied including prescriptions and symptoms
3. How Wayne Presented - both physically and mentally in general
4. Other (the referral letter from his General Practitioner)

To make a dependence diagnosis we take into consideration the Patient Background, as outlined in Section One of this report. This helps us to form the overall clinical picture. Furthermore, observations are made during consultation to help in assessing the patient’s condition.

2.1.3

Guidelines / Criteria Used to Make Diagnosis

In Wayne’s case the guidelines / criteria used to make the diagnosis was as follows:

1. DSM-IV-TR Criteria
2. ICD-10 Criteria

To diagnose Benzodiazepine dependence we use the DSM-IV-TR Criteria here at the Alcohol & Drug Service. The DSM-IV-TR is the standard used by the American Psychiatric Association.

As noted in the DSM-IV-TR, drug dependence is a maladaptive pattern of drug use leading to clinically significant impairment or distress, which is manifested by 3 or more of the Criteria occurring at any time in the same 12 month period.

In Wayne’s case the clinical impairment included both physical and mental symptoms, and associated with this impairment was the impact on Wayne’s life, which included his inability to function at work. 

As a back-up to the DSM-IV-TR Wayne’s clinical picture was measured against the ICD-10 criteria which is used more commonly in Europe to diagnose substance dependence.

2.1.4

Procedure Used to Arrive at Diagnosis

The first thing we had to do was consider the referral received from Wayne’s GP, which suggested to us that Wayne had a problem with Benzodiazepine dependence.

We then proceeded to assess Wayne and interviewed him to find out about his history. For example: what kind of Benzodiazepines he had been taking, dosages, period of use etc.

NB: The dependence diagnosis in Wayne’s case was made easier simply by the fact that he was being prescribed Benzodiazepines (Chlordiazepoxide 15mg, Clonazepam 0.9mg, Tofisopam 150mgs) for over a 6 month period.

We also analysed Wayne’s history of symptoms in order to help us identify symptom patterns that are consistent with Benzodiazepine dependence. For example: tolerance, withdrawal etc.

Other general history such as unsuccessful attempts at reduction was also noted.

Once a complete analysis of Wayne’s background / history had been carried out we then matched this information against the DSM-IV-TR Criteria.

The first criteria – tolerance and withdrawal are evident in how Wayne presented to the service and in that the symptoms he reported were consistent with these. Regarding the criteria of loss of control, impact on life and continued use, it was found that Wayne met these based upon the history he gave both myself and the Detox nurse.

Before concluding that Wayne met these criteria we cross-checked his verbal self reports with the documentation that he presented, his Doctor's referral letter and reports from his family.

Matching Wayne’s background / history against the DSM-IV-TR Criteria enabled us to confirm the diagnosis of Benzodiazepine dependence.

2.2 Overall Clinical Picture

In order to determine whether a patient is drug dependent, we must consider the history provided by the patient to help us form the overall clinical picture. In Wayne’s case the main points are as follows:

1. The patient was healthy and well up until 1999

2. The patient had no previous history of psychological, neurological or anxiety disorders

3. The patient did experience some work related stress symptoms from around October 1999 for the first time

4. The patient’s work related stress symptoms did subside, however, after he changed jobs in March 2000

5. The patient experienced, what was diagnosed as an unrelated acute rotational vertigo attack on 11th May 2000

6. The patient developed anxiety related symptoms after not being able to receive any clear-cut diagnosis for his vertigo attack

7. The patient was prescribed Benzodiazepines, which are addictive medicines, even in small prescription doses, especially when taken over prolonged periods of time

8. Benzodiazepines have numerous commonly known untoward side-effects, e.g. ocular effects, lethargy, palpitations

9. The patient’s overall dose was sufficient enough to form dependence

10. The patient experienced an initial settling of symptoms a couple of weeks into the treatment

11. The patients condition ceased to improve after about 1 month into the treatment

12. The patient complained that his condition was deteriorating and that he had developed some new symptoms after about 1.5 months into the treatment

13. The patient continued to develop new symptoms in this manner throughout the remaining period of the treatment

14. The patient’s additional post drug treatment symptoms were all consistent with Benzodiazepine withdrawal

15. The patient had 3 unsuccessful attempts at reducing – The patient showed a desire to reduce but was unable to do so

16. The patient showed an awareness that his condition was deteriorating and sought alternative help on at least 2 different occasions

17. The patient self reported that his ability to partake in social and recreational activities was significantly reduced

18. The patient’s GP reported that he eventually reached a state of complete exhaustion and confusion to the point where he was unable to work any longer

19. The patient GP reported that his condition was such that he was forced to return to his home country, where it took about 15 months before he was fit enough to work again

20. The patient required professional assistance in order to be able to reduce

21. The patient displayed withdrawal symptoms during the formal reduction process

22. The patient’s condition continued to improve following the completion of his formal withdrawal program

23. The patient had recovered from almost all of his post drug treatment symptoms within the first year of cessation with the exception of some residual anxiety complaints, namely panic attacks

24. The patient’s original complaint on presentation back in Japan, namely dizziness, also began to improve significantly for the first time following complete cessation of the drug regime

25. The patient’s overall mental and physical wellbeing improved following complete cessation of Benzodiazepines

2.3 DSM-IV-TR Criteria

As previously mentioned, the criteria we used to diagnose Wayne’s Benzodiazepine dependence is that used by the American Psychiatric Association, namely the DSM-IV-TR. The DSM-IV-TR has 7 Criteria of which 3 need to be met for a diagnosis of substance dependence to be determined. These 7 Criteria are as follows:

1. Has this person developed tolerance to Benzodiazepines?
2. Has this person developed withdrawal Symptoms to Benzodiazepines
3. Was the substance (Benzodiazepines) taken in larger amounts or over longer periods than intended?
4. Does this person have a persistent desire or made one or more unsuccessful efforts to cut down or control use?
5. Was a great deal of time spent in activities necessary to get Benzodiazepines, take Benzodiazepines or recovery from its effects?
6. Has this person reduced other activities as a result of their Benzodiazepine use?
7. Has this person continued Benzodiazepine use despite problems caused by or exacerbated by use?

Of the 7 Criteria above, Wayne met numbers: 1, 2, 4, 6, 7 above, in other words, Wayne met 5 out of the 7 Criteria, for which only 3 need to be met in order to determine dependence.

1. Tolerance

Tolerance was evident in the fact that Wayne reported some settling of his symptoms (1.4.5, pg 6), but soon afterwards his symptoms started to return along with the others (1.4.6, pg 6). The re-emergence of symptoms in this case is consistent with the fact that he met the criteria for tolerance.

Drug dependence, or in Wayne’s case, Benzodiazepine dependence is related to chronic ongoing drug use, which results in an altered neurophysiological state that develops as a result of tolerance.

Tolerance is defined as “the reduction in response to a given dose of a drug after repeated administrations”. The effects associated with tolerance are evident in the direction counteracting the acute drug effects to maintain system level homeostasis in the individual concerned.

NB: Tolerance can be formed in as little as 4 weeks on higher doses of Benzodiazepines and with therapeutic anxiolytic doses (up to 40mgs Diazepam daily equivalent) significant dependence can occur after four to six months of daily dosing (Textbook of substance abuse treatment second edition, Principles of addiction medicine third edition). (Wayne’s history indicates he was prescribed therapeutic doses of Benzodiazepines for longer than 6 months)

2. Withdrawal Symptoms

As highlighted by Dickenson et al (Management of sedative-hypnotic intoxication and withdrawal in ASAM Principles of addiction medicine); “a withdrawal syndrome can follow discontinuation of short term (2 to 3 months) low dose therapeutic use but most symptoms if present at all, are rated as mild and are easily managed. On discontinuation of long-term (1 year) therapeutic (low dose) use, withdrawal is common and is accompanied by moderate to severe symptoms in 20% to 100% of patients.”

In Wayne’s case, as he had been prescribed Benzodiazepines ongoing for almost 10 months by the time he was reviewed at our service, it was very likely that he would have had withdrawal symptoms simply based on the length of time he was prescribed Benzodiazepines for.

Wayne met the criteria for withdrawal, which was made evident by the following symptoms which emerged during the course of his treatment, or initially got worse on reduction of his overall dose:

1. Tingling sensation over face
2. Loss in coordination
3. Myoclonic jerks
4. Oily smell in body odour
5. Increased joint pains
6. Tightening of muscles
7. Worsening of dizziness
8. Worsening of pulsating temporal arteries
9. Worsening of visual disturbances
10. Increase in emotional instability
11. Increased palpitations
12. Tightening in chest
13. Flushing
14. Hypersensitivity

4. Loss of Control

Wayne met the criteria for loss of control or unsuccessful attempts to cut down or control his use. This was evidenced by the history of unsuccessful attempts to cut down his Benzodiazepine use on his own (1.2.7, pg 2), which remained unsuccessful until he sought help in a formal withdrawal program from our service.

6. Impact on Life

Following the commencement of Benzodiazepines, Wayne experienced a number of significant impacts on his life, which included the following:

1. Loss in ability to work (over 14 months)
2. Relationship difficulties, including family, friends and romance
3. Loss in ability to take part in recreational activities
4. Loss in ability to socialize

Based on the above Wayne met the criteria for important social occupational recreational activities having been reduced due to his Benzodiazepine use.

NB: I understand that Wayne has comprehensive information regarding his history of difficulties with occupational and recreational activities during the period that he was prescribed his Benzodiazepines.

Furthermore, I understand the above impact on Wayne’s life has been confirmed by Senior Clinical Psychologist, Dr. Alan Guy, who has been assessing Wayne periodically since his initial assessment back in August 2001 (refer Dr. Alan Guy’s letter dated 27th April 2007).

7. Continued Use Despite Knowledge of Harm

We know Wayne was aware that his condition was deteriorating by the fact that he was making lists of new symptoms and handing them to Dr, X.

Furthermore, Wayne made 3 attempts to reduce the drug regime, but found himself continuing to take the Benzodiazepines that were prescribed for him, despite the knowledge that they could possibly be harming him.

Therefore, Wayne also meets the criteria for continued use despite persistent or recurrent psychological problems due to his use of Benzodiazepines.

NB: These symptoms did not start to remit until Wayne successfully withdrew from his Benzodiazepines and his withdrawal symptoms began to settle.

2.4 ICD-10 Criteria

Alternatively, if the ICD-10 Criteria for diagnosing Benzodiazepine dependence (recommended by the World Health Organisation) is applied, we can see that Wayne also met the criteria for this as well.

As defined by the ICD-10, the diagnosis of dependency is made if 3 or more criteria are met. If one reviews the ICD-10 Criteria one can see that Wayne met the following:

1. Difficulties in controlling the substance in terms of its termination.  As discussed above, Wayne had difficulty reducing and stopping his Benzodiazepines on his own without medical assistance.

2. A physiological withdrawal state, as described above.

3. Wayne had evidence of tolerance as discussed previously.

4. Wayne also neglected his alternative pleasures or interest that he got from life.  This is evident in his personal statement where he describes withdrawal and his friends’ reports that he appears to be losing pleasure from life.

5. He also met the criteria with persisting with use of Benzodiazepines despite evidence of harmful consequences.

NB: As Wayne met 5 of the Criteria, he clearly also meets the ICD-10 Criteria for “Substance Dependence Syndrome”.

2.5 Differential Diagnosis

2.5.1

Anxiety

Benzodiazepines are known to cause the very symptoms that they are designed to treat; i.e. anxiety related symptoms. This is due to tolerance and subsequent breakthrough symptoms.

Wayne had no prior history of suffering from an anxiety disorder, which has been supported by Dr. ter Haar’s letter, dated 19th October 2006. He did experience some mild stress symptoms at a stressful job around October 1999, but these mostly disappeared after he changed jobs a few months later.

In my professional opinion, the anxiety symptoms that Wayne developed following his Benzodiazepine based drug treatment were likely to be the result of Benzodiazepine dependence.

2.5.2

Previous Effects of Tobacco, Alcohol and Marijuana

As previously outlined (articles 1.2.3 & 1.2.4, pg 2), we know that Wayne experimented with tobacco, drinking and cannabis during his teenage years. The current research to suggest these are a gateway drug to ongoing further substance use is not yet conclusive either way.

In Wayne’s situation they are unlikely to be gateway drugs as Wayne otherwise had no other Psycho-social risk factors (eg peer group, his profession, family history of substance use etc) that would make it more likely of him to develop substance dependencies.

Furthermore, hallucinogen flashback symptoms are not proven to occur in those who have previously used cannabis and ceased its use.