3.1 Dr. ter Haar's File - History of Complaints (9 Mar 1989 ~ 18 Jun 1996)

3.1.1

Below is a list of complaints taken from Wayne’s history under Dr. ter Haar that may be used to try and rule out certain symptoms associated with his Benzodiazepine dependence. Subsequently, I would like to take this opportunity to differentiate between these previous complaints and the dependency symptoms in 2000 ~ 2001.

(Pg.1: Low back pain)

3.1.2

We know that Wayne had a previous history of periodic lower back pain since straining his back lifting heavy lumber in March 1989 (discussed in Article 3.3.17 of Report 3).

It may be argued that the “muscle stiffness” Wayne experienced during the drug treatment in 2000 ~ 2001 was attributable to his previous episodes of “low back pain”.

As mentioned in Report 3, the “muscle stiffness” associated with the dependence was not localized or limited to one area; rather it encompassed his entire body. This general all over “muscle stiffness” is supported by the fact that Wayne began a course of regular full-body deep tissue massage from November 2000 (following 4~6 months of Benzodiazepine exposure) at a local physiotherapy clinic in Saitama to help try and alleviate this. NB: I have been informed that the physiotherapy clinic has supplied Wayne with a letter explaining this muscle stiffness and subsequent course of full-body massage therapy.

(Pg.1: Left shoulder pain)

3.1.3

Wayne suffered from recurring left shoulder dislocations following a sporting incident in 1985. This continued to cause him discomfort until after he had recovered from the subsequent operation done by orthopedic surgeon, Tim Astley, in 1991.

It may be argued that the additional “shoulder stiffness” (Report 3, Article 2.1.3 / Evidence Koh A12) Wayne experienced during the drug treatment in 2000 ~ 2001 was attributable to his previous dislocations and subsequent operation.

However, the pain associated with the above, had already resolved itself following a course of strengthening exercises and physiotherapy before Wayne travelled to Japan in 1999. This is supported by the entry on page 4 of Dr. ter Haar’s patient file, where it says “Good result from shoulder repair”. Further, the pain associated with the shoulder dislocations, was limited to the left side only. The “muscle stiffness” associated with the dependence, however, included, not only both shoulder areas, but the entire body, as explained above.

3.1.4

We can see from the above history, a number of Wayne’s previous complaints occurred as separate individual cases, under different circumstances at different periods in time, and were not accompanied by other groups of symptoms.

Whereas, the dependency symptoms all occurred under the same circumstances at the same time and were accompanied by other symptoms consistent with dependence. Further, all of the symptoms associated with Wayne’s dependency increased again during the withdrawal process and then they improved after the drugs had been removed.

3.1.5

Considering the above within context of the overall clinical picture (Report 1, Article 2.2) and the fact that Wayne met 5 criteria of the DSM-IV-TR within the same 12 month period, it is clear that Wayne’s previous history was not a contributing factor to his condition in 2000 ~ 2001, rather it was caused by Benzodiazepine dependency.

NB: Wayne was a regular patient of Dr. Barry ter Haar from 9 Mar 1989 ~ 18 Jun 1996. He then travelled to Japan in July 1996 to undertake a public relations job. After, he returned in August 1998, he relocated to Waitara and subsequently, became a regular patient of Dr. Whitwell from 4 Sep 1998 (See below).

3.2 Dr. Whitwell's File - History of Complaints (4 Sep 1998 ~ 1 May 2002)

3.2.1

Below is a list of complaints taken from Wayne’s history under Dr. Whitwell that may be used to try and rule out certain symptoms associated with his Benzodiazepine dependence. Subsequently, I would like to take this opportunity to differentiate between these.

(Pg.3: Long History of Slightly Stiff Neck)

3.2.2

We know that Wayne had a previous history of periodic neck pain, which according to Wayne, first developed in late 1997 whilst doing prolonged desk work using a laptop computer with poor ergonomics at the Miyazaki Local Government Office (discussed in Article 3.3.17 of Report 3). NB: Dr. ter Haar’s patient file above shows that Wayne had no history of neck pain prior to 1997.

It may be argued that the “muscle stiffness” Wayne experienced during the drug treatment in 2000 ~ 2001 was attributable to his “long history (3 years) of slightly stiff neck”

However, once again, the “muscle stiffness” associated with the dependence was not localized or limited to one area; rather it encompassed his entire body and had worsened to the degree that his jaw began locking up.

(Pg.3: Pain in between shoulder blades)

3.2.3

On 4th September 1998 Wayne also complained of “pain in between shoulder blades (leading up to neck)”.

It may be argued that the “muscle stiffness” Wayne experienced during the drug treatment in 2000 ~ 2001 was attributable to this “pain in between shoulder blades”

However, as with previous muscular complaints, this was localized, whereas, the “muscle stiffness” associated with the dependency encompassed his entire body. Further, Wayne reports that the episodes of “pain in between shoulder blades” are periodic in nature and are triggered only by strenuous exercise, which is supported by the note in Dr. Whitwell’s patient file where it says “Lifting weights at gym”.

(Pg.3: Long History Mild Lower Back Pain)

3.2.4

Refer to Article 3.1.2 above for discussion on this.

(Pg.3: Long Standing Anxiety Depressive Problem)

3.2.5

On 29th March 2001, there is an entry saying “long standing anxiety depressive problem”, which may suggest that Wayne’s anxiety symptoms were caused by an underlying anxiety condition. Also, there are several other entries throughout Dr. Whitwell’s patient file referring to anxiety and depression symptoms.

3.2.6

I would agree that Wayne was suffering from anxiety symptoms; however most of the symptoms he presented with to our service in April 2000, were likely caused or exacerbated by Benzodiazepine dependency and not an underlying anxiety condition. The reasons for this are as follows:

1. Wayne’s prior history, spanning 10 years (including Dr. Whitwell’s file) shows that he had no previous psychological conditions (including any anxiety problems) or neurological complaints prior to travelling to Japan in 1999 documented in his available medical notes.

2. Benzodiazepines can cause simple stress symptoms to worsen, and can lead to the development of panic attacks etc during the treatment, which is well documented in the literature (Report 3, Article 3.3.15).

3. The fact that Wayne’s condition worsened during the treatment to the point where he was unable to work.

4. Like his other dependence symptoms, the anxiety and depression type symptoms intensified again during the formal reduction process, and like his other dependence symptoms, the anxiety and depression type symptoms continued to improve following completion of the initial withdrawal phase of his formal withdrawal program – in the absence of Benzodiazepines, although, many symptoms did wax and wane for several months, which is consistent with a protracted withdrawal syndrome.

5. Wayne has since been able to make a return to living and working in Japan, and despite being under considerable more stress on this occasion with his ongoing case for compensation, he continues to maintain a much better state of health.

(Findings)

3.2.7

There is no question that Wayne had symptoms of anxiety and depression in 2000 ~ 2001. The only question is: to what degree were these symptoms (anxiety / depression) patient related and to what degree were they caused by Benzodiazepine dependency.

3.2.8

Based on the aforementioned reasons, and the reasons outlined in Report 3, Article 3.3.12, it is most likely that the majority of Wayne’s anxiety type symptoms upon presentation to our service were caused by Benzodiazepine dependency.

3.2.9

The one exception to Wayne’s recovery from these symptoms following his abstinence from Benzodiazepines was that he did continue to suffer from panic attacks, albeit to a lesser degree over time. However, this needs to be analyzed taking into consideration the long term effects including; protracted withdrawal, the trauma of the dependence experience, and the additional pressures of his subsequent case for compensation.

3.2.10

We do know, however, that Wayne had no history of panic attacks before being exposed to Benzodiazepines.

3.2.11

The difficulty of being able to differentiate between symptoms of anxiety and those of dependency is one of the big problems with Benzodiazepines because it often results in the overprescribing of these drugs. Quite often, the formation of dependency is overlooked, resulting in doctors thinking that the patient’s anxiety condition has worsened. The patient’s prescriptions are sometimes increased followed by a temporary alleviation of symptoms; however, this often leads to the compounding of the dependency problem.

3.2.12

In addition to the above, when put into context of the overall clinical picture (Report 1, Article 2.2) and considering the fact that Wayne met 5 criteria of the DSM-IV-TR within the same 12 month period, it becomes clear that most of the (chronic) anxiety and (chronic) depression symptoms Wayne had in 2000 ~ 2001 were most likely caused or exacerbated by Benzodiazepine dependency.

3.3 Mental Health & Addiction Services - History of Complaints

(Pg.8: Depression)

3.3.1

On page 2 of Wayne’s typed notes upon presentation to our service (page 8 of the Mental Health & Addiction Services patient file) there is a list, which corresponds with that on page 12 of Dr. X’s patient file under the title “NB”.

3.3.2

We can see there is an additional comment included in this list, which was not originally included in the version given to Dr. X. This additional comment is: “Have started to feel depressed and closed in since vertigo attack.”

3.3.3

Wayne reports that following his initial vertigo attack and subsequent balance problem, he had some difficulty going out and socializing, as he usually would.

3.3.4

Subsequently, it may be argued that the “Impact on Life” outlined in Article 2.4 of Report 3, was caused by the initial vertigo attack and balance problem thereafter, as opposed to Benzodiazepine dependency.

3.3.5

However, once again, this needs to be considered in context. For example, we know that Wayne was still able to work in Japan, albeit on light duties, before the Benzodiazepine treatment began and during the early stages of the treatment, but following more than 4~6 months of Benzodiazepine exposure, his condition continued to deteriorate and eventually he ended up in a state where he was unable to work at all again for a period exceeding one year.

3.3.6

This suggests that the Benzodiazepine dependency had the greater impact because Wayne was still able to work following his initial complaint of vertigo and subsequent balance problem, but he was not able to work following his drug treatment. 

(Pg.17: Counseling)

3.3.7

On page 17 of the patient file, there is an entry on 30th April 2001 saying that Wayne had requested general counseling as opposed to specialist D/A (Drug & Alcohol) counseling.

3.3.8

Wayne in written communication has reported that the reason why he requested general counseling was because, after having been briefed on the nature of Benzodiazepines, including dependence and withdrawal, he felt he knew what needed to be done as far as stopping was concerned, and subsequently, did not feel that he needed any extra counseling for this. Rather, he wished to seek advice regarding grief etc. with regards to his situation at the time.

(Pg.25: Stressors)

3.3.9

In my letter to Dr. Whitwell, dated 5th June 2001, I mentioned that Wayne was encouraged to look at alternative relaxation techniques to help him cope with some of the stressors he had described. These stressors refer to the previous work related stress at his job in Shizuoka in late 1999 / early 2000, the fact he suffered from an undiagnosed vertigo attack that had left him with a ongoing balance problem for a period, and the fact that he had been suffering from Benzodiazepine dependency, which had subsequently impacted on his life including his ability to work.  

(Pg.22: Visual Disturbances)

3.3.10

Further to Articles 3.3.16~21 of Report 3, which gave examples on how some of the symptoms relating to Wayne’s original complaint (muscle stiffness and hypersensitivity) worsened in the presence of Benzodiazepines, the worsening of visual disturbances gives another example of this.

3.3.11

Page 11 of Dr. X’s patient file shows that Wayne was experiencing sensitivity to light and flickering in his vision following his initial vertigo attack.

3.3.12

However, we can see from the notes on page 21 of the Mental Health & Addiction Services patient file that Wayne later complained of an increase in light sensitivity, colour flashes, exaggerated after images, flashes, staggered focus etc following 4~6 months of Benzodiazepine exposure. This worsening of visual symptoms is also suggestive of withdrawal.