Below is an explanation of how we were able to determine Wayne’s initial dependency diagnosis based on the information we had in our files before the proceedings for compensation commenced.

NB: As a result of Wayne’s legal case for compensation, more and more questions have been asked, and subsequently, a lot of additional information has surfaced after the fact, such as the content of the patient files from Japan. Most of this additional information was considered and applied to the dependency diagnosis in Report 3. Although a lot of the additional information retrieved after the fact actually supports the dependency diagnosis, in this section of Report 4, I would like to focus on the method used in making the initial dependency diagnosis upon Wayne’s presentation to our service in April 2001.

2.1 Diagnostic Procedure

Refer to Report 1, Articles 2.1.1~4 for explanation of this.

2.2 Original Grounds for Diagnosis (Etiology)

2.2.1

As explained in Report 1, one of the first things we did was to consider the referral form from Wayne’s GP, Dr. Whitwell. Noted in this referral was the fact that Wayne had a very strong desire to stop and yet was having difficulty reducing. This is evident where it says “attempting reduction without complete success. Patient very keen to get off these meds”.

2.2.2

Noted in Wayne’s history upon presentation was the fact that he had been prescribed multiple combinations of Benzodiazepines and a tricyclic antidepressant for almost a 10 month period by the time he was assessed at our service. Subsequently, we were able to determine that there was at least a 50~100% chance that he was dependent simply based on the duration and dosages of his prescriptions alone.

2.2.3

Based on the interviews with Wayne, we were able to form the initial overall clinical picture (Report 1, Article 2.2). Through these interviews we were also able to determine the fact that Wayne did not have an addictive personality. This was made evident by his keenness to distance himself from the Benzodiazepine regime and his history (See page 5 of patient file).

2.2.4

Also taken into consideration was the application of the DSM-IV-TR (See next page).

NB: We also carried out some tests including thyroid function test, blood glucose test and full blood count (See page 17 of patient file). These were done to check if there was any other reason that could have explained his feeling of "lousy". I usually do these to rule out more common forms of tiredness, which I was able to do in Wayne’s case. Also done at the time were U&E (check renal function), LFT's (check liver function) and all results did come in the normal range.

2.3 DSM-IV-TR Based on Initial Assessment

2.3.1

The DSM-IV-TR criteria can be applied to Wayne’s initial assessment, as follows:

(1) Tolerance

Tolerance was evident in the fact that Wayne reported some settling of his symptoms, but soon afterwards his symptoms started to return along with others. This is supported by the comment on page 3 of Wayne’s typed notes upon presentation to our service (page 9 of the patient file) where it says “Although my condition had stabilized to a certain extent (initially), I continued to suffer from most of the aforementioned symptoms….Furthermore, additional symptoms began to appear…”

Further, as outlined in Report 3, Article 2.1, the fact that Wayne produced withdrawal symptoms upon reduction at our service also confirms that he had developed tolerance. This is due to the fact that withdrawal and tolerance are interrelated because if a patient does not have tolerance, then there is no neuro-adaptation, and thus no withdrawals will occur (Report 2, page 1).

NB: Refer to Report 3, Article 2.1 for additional information regarding the application of the criteria for Tolerance.  

(2) Withdrawal

2.3.2

As mentioned in my first letter, dated 10 Sep 2004, when Wayne first presented to our service on 19th Apr 2001, he had a full comprehension of his history and presented it to both myself and the Detox Nurse in typed form (See pages 7~11 of patient file). It was noted that many of the symptoms contained in this history were consistent with Benzodiazepine withdrawal and or side effects.

2.3.3

As outlined in Report 1, Article 2.3 – 2, 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.

2.3.4

Wayne met the criteria for withdrawal, which was made evident by the following symptoms, which either initially emerged during the course of his treatment due to tolerance (Report 3, Article 2.2.3) or initially got worse or first developed on reduction of his overall dose as recorded in the patient file and shown below:

As outlined in Report 1, Article 3.1.6, our service provided Wayne with information on Benzodiazepines at his first consultation on 19th Apr 2001. This included information on what they are prescribed for, how they work, the nature of side-effects and withdrawal and how to identify the symptoms.

2.3.5

With this increased awareness, Wayne was able to identify several other withdrawal symptoms, which he provided by way of a typed list at his final consultation on 21 May 2001 (See pages 21~22 of patient file). This list of withdrawal symptoms included those that he had first developed during the drug treatment and new ones that he developed after stopping completely on 5 May 2001.

NB: In my letter to Dr. Whitwell, dated 5th June 2001, I mentioned that when Wayne reduced his dosage he noticed the symptoms of dizziness, pulsating temporal artery, and headaches returned, but they quickly settled over the following five days after reduction. This means that the symptoms had settled back to the level they were before the previous step in reduction – it does not mean they settled completely.

To explain further, this refers to the fact that each time Wayne reduced, he experienced a worsening of symptoms. He also had numerous other withdrawal symptoms in addition to the above (See pages 10, 11, 21, 22 of file) and many of them did not begin to settle completely until after about 6 months following complete cessation. This is supported by the entry in Dr. Whitwell’s patient file in November 2001, where it says “slow improvement in most areas” and again in January 2002, where it says “Symptoms – most improving except ocular”. Also noted in January 2002 was the fact that Wayne’s pulse rate had returned to 68 (normal) from 90 (tachycardia) recorded on page 3 of the O Medical Center patient file.

NB: Refer to Report 3, Article 2.2 for additional information regarding the application of the criteria for Withdrawal. 

(4) Loss of Control

2.3.6

Regarding the criteria for loss of control, it was noted in Dr. Whitwell’s referral form to our service that Wayne was “attempting reduction without complete success” (See page 23 of Mental Health & Addiction Services patient file).

NB: One can see the following entry made by Dr. Whitwell in his patient file on 9th April 2001.

Tired      –      on

Alprazolam        0.4mg  1 bd

Rivotril                0.4mg  1 bd

Having problems with withdrawal

Control

Add Fluoxetine 20mg

?? look at home detox

This supports Article 2.3 of Report 3 for Loss of Control.

Further, this is consistent with Article 2.3 of Report 3, which highlights the fact that Dr M was also not sure whether or not to reduce Wayne’s intake from 3 to 2 times a day because of the symptoms worsening.

2.3.7

Other unsuccessful attempts at reduction became clear after proceedings for compensation had commenced (See Article 1.5.1 above).

NB: Refer to Report 3, Article 2.3 for additional information regarding the application of the criteria for Loss of Control. 

(6) Impact on Life

2.3.8

When Wayne presented to our service, it was clear that he had suffered an impact on his life due to the fact that he was no longer able to work.

2.3.9

As outlined in Report 2, of particular note was the fact that he was still able to work in Japan, albeit on light duties, before the treatment began, but he struggled to complete his contract during the course of the treatment (subsequently cut short), after which he ended up in a state where he was unable to work at all again for over one year.

NB: Refer to Report 3, Article 2.4 for additional information regarding the application of the criteria for Impact on Life. 

(7) Continued Use Despite Knowledge of Harm

2.3.10

As outlined in Report 3, Article 2.5.1, the fact that Wayne always produced detailed notes regarding his condition upon consultation shows that he is the type of person who is aware his condition.

2.3.11

Noted in the history that Wayne presented to our service was the list of additional symptoms that he developed following approximately 4 months of drug treatment. Further, after showing awareness that he had developed these new symptoms, he endeavoured to seek alternative help from another hospital (See page 10 of patient file).

2.3.12

Despite showing awareness that the drugs were possibly causing him harm, he continued to use, which supports the criteria for Continued Use Despite Knowledge of Harm. 

NB: Refer to Report 3, Article 2.5 for additional information regarding the application of the criteria for Continued Use Despite Knowledge of Harm.

2.4 Symptoms on Presentation

2.4.1

Also taken into consideration upon Wayne’s presentation to our service was the list of symptoms contained in his typed notes (See pages 10~11 of patient file). I note that the symptoms contained in this list are consistent with those referred to in Report 3, Article 2.1.3 / Evidence Koh A12, and Article 2.2.3 / Evidence Koh A26.

2.4.2

I also note that there are some slight variations. For example; according to Evidence Koh A12, Wayne first developed the palpitations following 1.5 months of Benzodiazepine exposure, but according to his typed note on page 10 of the patient file, he developed palpitations from October.

2.4.3

Also, on page 2 of Wayne’s typed notes (page 8 of patient file) he lists “jaw pain” under the group of symptoms as at 16th May 2000, following his initial vertigo attack. Wayne in written communication has since reported that this was a mistake and that he did not develop any tightness in his jaw until about October 2000, when it started to lock up and was accompanied by a general stiffening of muscles encompassing his entire body (Report 3, Article 3.3.17).

2.4.4

This is consistent with the fact that there is no mention of jaw pain / stiffness in any of the other documentation, including any of the patient files, before it was first noted in Wayne’s handwritten note to Dr. X in December 2000 (Report 3, Article 2.2.3 / Evidence Koh A26).

2.4.5

According to Wayne’s first statement (Page 8, Article 7), he did not bring the psychological symptoms (that he developed during the treatment) to the attention of Dr, X for fear of being committed to a psychiatric institution in a country different from his own.

2.4.6

However, he did complain of these symptoms upon presentation to our service. These included feelings of being hyper and nervy, emotional instability, (chronic) anxiety, feelings of being on the verge of having a fit / going mad, mood swings, (chronic) depression, feelings of having a nervous breakdown and confusion (See page 21 of patient file).

2.4.7

The mood swings and aggressiveness were also noted in statements from friends and family (Report 3, Articles 2.4.3~4).

2.4.8

The panic attacks were initially described as episodes of being hyper and nervy, emotional instability, being on the verge of having a fit etc, but were not recognized as being panic attacks as such until after most of Wayne’s other symptoms had subsided and after he had learnt more about the untoward effects of Benzodiazepine dependency through various publications and through our follow-up discussions at the time of writing Report 1.

2.4.9

As outlined in Report 3, Article 1.2, when determining a diagnosis for dependence, it is not sufficient enough to simply analyze symptoms, rather everything needs to be considered in context including; the patient background / history, overall clinical picture, application of the DSM-IV-TR criteria and the combined relationship of this information.

2.5 Recovery (additional information)

2.5.1

It was noted in Report 3, Article 3.1.2, that Wayne recovered from most of his symptoms within the first year of cessation with many symptoms subsiding within the first 3 months. It was also noted in Article 11 of the summary that he “recovered from most of his symptoms within about 3 months of completing the initial withdrawal phase”. Given that the initial withdrawal phase took several months, and that many of his symptoms started to improve 3 months after that, it would mean that he was starting to show signs of recovery after about 6 months of stopping.

2.5.2

This can be confirmed by the entry made in Dr. Whitwell’s file on 1st November 2001, where it says “slow improvement in most areas”.

2.5.3

Further, the fact that Wayne continued to make a steady recovery with time is supported by the entry made in Dr. Whitwell’s file on 8th January 2002, where it says “Symptoms – most improving except ocular. Is looking at going back to work”.

2.5.4

As outlined in my first letter, dated 10 September 2004, when I saw Wayne again in January 2003 and again in April 2003, it was apparent that he had been making a significant improvement in his state of overall physical and psychological health since he was first referred to our service. This is supported by the entry made by Psychologist Alan Guy, which says “Presented looking very well + reporting a stable increased weight than when last seen here. No obvious mood disorder”. Also, noted was the fact the he had remained Benzodiazepine free since he was discharged back in May 2001 (See Mental Health & Addiction Services patient file, page 19).

2.5.5

Further, when I saw Wayne again in September 2004, it was apparent that his condition continued to improve in the absence of Benzodiazepines. This was noted in the file where it says “Today he is healthier & fitter than before (April 2003). Wayne looks well in appearance - bench presses 180 kg”.

NB: Wayne has since informed me that he was actually squatting 180 kg, and bench pressing over 100kg. Nonetheless, it was a significant improvement considering that he was having difficulty just walking when we first saw him.

2.6 Records

2.6.1

You will note that my consultations with Wayne were recorded in the Mental Health & Addiction Services patient file as far as 8th 2004.

2.6.2

All of the additional work done regarding Wayne’s case for compensation since then has been done on a volunteer basis in my own time. Subsequently, no hospital records regarding Wayne’s case were maintained after September 2004.