甲A第絹号証誓嘉

MedicalReport（3）Re：WayneDouglas−BenzodiazeplneDependence

Preparedby：Dr．GraemeJudson

ServiceClimicalDirector
・MentalHealth＆AddictionServices

TaranakiDistrictHealthBoard
Preparedfor：TokyoHighCowt

Date：

Signature：

∵r

〜・ブ

烏卜占

遥遠豆Å孟藍歯髄宣32Contents

SectionPages

Subjectb仕Oduction（1）BackgroundInformation1

1．1

CharaCteristicsofBenzodiazeplneS2

l．2

DiagnosingBenzodiazepineDependence

2〜3

l．3

（2）DSMⅣ−TR＆PatientFiles

2．1

Tolerance

4〜6

Withdrawa1

6〜11

2．3

LossofContro1

11

2．4

ImpactonLife

3．1
3．2
33

3．4

ContinuedUseDespiteKnowledgeofHarm

RecoveIY
ShortfallsinPrescnptionDoses
DiffbrentialDiagnosis

ConsistencyofPreviousR甲OrtS＆Evidence

3．5，FutureReports＆PossibleTestimony

SummativeConclusion

3

2．2

2．5

（3）General

Presc亘ptionDuration／Dosages＆PatientFiles

12〜13

13

14〜15

15
16〜21

21〜22

22

23〜24

q r1
QJ一も

Introduction

Ⅰunderstandtherehavebeensomediscrepanciesregardingthefollowlng：

1・TheapplicationoftheDSMⅣ−TRinrelationtotheevidence
2・Shortfa11SinprescnptlOndoses
3・PossibilityofaJHietydisorder
4・Consistencyofpreviousreportsinrelationtoevidence（patientales）

Subsequently，thisreportserveStOaddresseachofthese．

ARerhavinghadtheopportmitytoviewthetranscriptsofWayne，spatientfilesthatwereprovidedtome
byWayne，IcancoI血mthatthecontentoftheseBlesdoesnotalteranythingasfarasmaintainingthe
dependencediagnosisisconcemed．

Beforeoutliningthereasonswhy，IwouldliketotakethisopportmitytomakeitcleartOallrelevant
PartiesthatmyobjectiveregardingWayne，scaseissimplytodeteminewhetherhewasdependent．
ayne■SCaS（

MyobiectivedoesnotimoIvediagno
hJ17√、1、；aハ＋；T，△」〈凸nl＿〈

二＿＿＿▲1＿h J・＿

useofhisonglnalcomplaint，WhetheritbeSylvian
Lr￣￣▼▼￣ ▼▼￣￣￣r￣￣￣▲▲り▲▲レ▲⊥〉▲1L UヽノLフJlVlall

AqueductSyndrome（indicatedbyDr・『恥，Oranj三二二さ三千AcuteVestibulop叫（suspectedbyNewologiste，慧恕豊吉慧慧濫慧監禁慧霊霊≡蒜：監禁慧認慧lS・（AutonomousNervOuSDisorder）doesnotforgroundsforrulingoutdependence．
Thisr印OrtCOnSistsof3sectionsasfollows：

1・BackgroundInformation

2．DSMⅣ−TR＆PatientFiles

SectionOneisbasedonbackgroundinformationtoglVeabetterinsightintothenatureof
Benzodiazq）lneSandhowdependenceisfomedanddiagnosed．

SectionTwoisbasedfundamentallyontheevidenceinrelationtotheDSMIV−TRCriteria．

SectionTheeisalsobasedontheevidence，butincludesrationalewithregardstothedisputesoverthe
Shortfallsinprescnptiondoses，diだbrentialdiagnosisetc・andothergeneralinformation．

Therefkencenumberstoevidenceitemslodgedintheco血wereprovidedtomebyWayneandhis

lawyerandIhavenotbeenabletoverifythem血sthand，however，ItruSttheyareconsistentwiththe
COurtrecords．

1SectionOne

1．1CharaCteristicsofBenzodiazepines

l・1・l Benzodiazepinescanbeveryeffbctivefortreatinganurhberofacuteanxietyconditions，

especiallywherethepatienthasbeenexposedtosuddenorserioustrauma・However，

BenzodiazeplneSSOOnlosetheireffktandforthisreasonitisrecommendedthattheyarenOt
PreSCribedforanylongerthanabout2′司weeks．

1・1・2Also，theydonotmixwellwith0therdrugs，andtheyshouldnotbeusedinmultiple
COmbinationswitheachother，andsdbsequently，itisrecomendedthatnomorethanOne

kindisprescribedatatime，0therwise，thereisanincreasedpossibilityofside−efftctsand
dependencyforrnng．

1・1・3

AsBen加diazepmesareverye脆ctiveforshorttermtreatment，pahentswi111ikelyexperienceanimitialsettlingofsymPtOmSSOOnafterthetreatmentbegins．However，ifthetreatmentis
PrOlonged，itislikelythatthepatient，sbodywillneuro−adapti・e・developtolerance・Whenthis

happensthedrugSlosetheirtherapeuticefEbctandpatientsmaynoticearetuminsomeoftheir
SymPtOmSthatwereinitiallysuppressed・

1・1・4ThesymPtOmSCanORenbecontainedbyincreasingthedosageamOunis；however，thisusually

escalatesthestateoftoleranceandincreaseSthelikelihoodofwithdrawalsymptomsoccurnng
andisbestavoided．

1・1・5Incaseswherethetreatmentcontinueslongterm（anymOrethanafewmonthS），thepatient

becomesmoretolerantOfthedrugSandd印endencycanbeformed．ThiscanreSultin
withdrawalSymPtOmSOCCurnngduringthecourseoftreatment，aSWellaswhenthepatient
beginstoreduce・SomepatientsdaneXPerienceaProtractedWithdrawalSyndrome，VAichcan
lastforoverayear．

1・2DiagnosingBenzodiazepineDq）endenc寧1・2・1WhendiagnosingBemdiazq）inedependence，itiscommonpracticetousetheDSM−ⅣTR，WhichisthestandardusedbytheAmeriCanPsychiatriCAssociation．AsnotedintheDSM−IV
TR，drugdq）endenceisamaladaptivepattemofdruguSeleadingtoclinicallysigni鮎ant
impalrmentOrdistress，Whichismaniftstedby30rmOreOfthe7Criteriaoccurrlngatany

timeinthesame12monthperiod・
1・2・2Whenapplyingthesecriteria，itisnotasimplecaseoflookingateachofthemindividually・
Rather，theyshouldbelookedatinawaythatconsiderstheirrelationshiptooneanotherwithincontextoftheoveral1cli血Calpicture・2

1・2・3AIso，Whendoingasymptom，sanalysis，itisnotasimplecaseofsaymgthattheoriginal

SyPPtOmSmuSthavebeenduetoanXietyandthatthenewsymPtOmSmuSthavebeenduetodependence・ItisnotthatsimpleandclearCut．Quiteoftensymptomsofwithdrawalconsistof

OriginalsymPtOmSChanginginnature，frequencyandintensity；e・g・WOrSeningofsymptoms．
Further，BenzodiazepinedependenceoftenmimicstheverysamesymptomsthedrugSare
intendedtotreat．

1・2・4

Subsequently，itmustbemadeclearthatadependencediagnosiscannOtbemadeona

SymPtOmSanalysisalone，although，Certainsymptomspattemsdoactasusefulindicatorsfor
SPeCificconditionssuchastoleranCeandwithdrawal・Rather，SymPtOmSShouldbeconsidered
WithinContextoftheoverallclinicalpicture．

1．3PrescnptionDuratlOn／Dosages＆PatientFilesl・3・lThecontentofDr・−spatientfileclearlyshTWSthatheprescribedWayneamixtureof5
diffbrentdrugS，including3diffbrentBenzodiazeplneSandaTricyclicantidepressant，WhichCOntinuedforalmosta7monthperiodwithoutanychan野血dosa寧e・＿ThisreglmeWaSthen
PrOlongedwithnewprescriptionsofBenzodiazepmes，Whichincluded2di脆rentkinds，after

Waynesoughtaltemativetreatmentat
January2001．

1・3・2Subsequently，beforeweevenbegintoconsiderthecontentofWayne，spatientfiles，his

SymPtOmS，theoverallclinicalpictureandtheapplicationoftheDSM−ⅣTR，WeCanalreadydeterminethattherewasatleasta50〜100％chanCethathewasdependentsimplybasedon
thedurationanddosagesofhisprescriptionsalone．

NB：Thereasonfbrthewiderangeinpossibilityofdependenceisbecauseindividualityneeds
tobeconsidered．

●

3SectionTwo

2．DSM−ⅠVTR＆PatientFiles

BasedontheevidenceoutlinedinArdclel・3above，Weknowthattheprescnptiopdosesand
durationweresufncientenoughforWaynetohaveformedtolerance・Furthertothereference

glVenOnPage130fmyfirstreport，ProfもssorAshtonhasprovidedthefollowlnginformation：

乃Jerd乃Ceα乃d卸e乃あcecα乃あe′甲卵e乃ZO威喝ぬαre弘yeか堺的カrわ郷地∽

2−41〃e血乃ereね仰乃加わ7㍍777血e，♪γα叩ねわたrα乃Ceα乃d卸e乃あceゐαVe占ee乃

血のed年毎r娩ereg〟αr揖eげ2・∫−5777gqr血Z甲肌．H
NBl：WemustalsoconsiderthattherateanddegreetowhichtoleranCeformsisdifftrentfor
eachindividualandthisisthereasonwhyclosemonitoringlSSOimportant．

NB2：ItispossibletofbmtoleranCeOnbothlongandshortactingagents．

ThefactthatWayneproducedwithdrawalsymPtOmSuPOnreductionatourserviceinApri1
2001confirmSthathehaddevelopedtplerance．

NB：Asoutlinedinmysecondrqport・dated23rdDecember2008，WithdrawalandtoleranCeare
interrelatedbecauseifapatientdoesnothavetoleranCe，thenthereisnoneuro−adaptation，and

Subsequently，theonlyquestioniswhendidheBrstdeveloptoleranCeandwhatwerethesigns．

重唾皇墜
1・Resurfacingand／orworsenlngOforiginalsymptoms
2・FailureofdrugStOCOntaini11nesslongterm

3・Developmentofwithdrawalsymptomsduringtreatment（SeeArticle2．2）

4・DevelopmentofwithdrawalsymPtOmSuPOnreduction（SeeArticle2．2）（1）Resurfacingand／orWorseningofOriginalSymptoms

2●1●1誤認崇慧守緊慧慧慧紀霊詣器だ悪霊慧md
Writtennote）．

2・1・2ThecontentofDr・『■
2000spatie聖meshowsthefollowingentrymade。n19也J。1yShoulderache，muSCletenslOnOnneCk−NoneH（Seepage8）．

NB：Thisisconsistentwithreports丘omWayneuponpresentationtoourservicesaymg

thatheexperiencedanimitialsettlingofsymPtOmSfollowlngthefirst20rSOWeeksof
histreatment・OthersymPtOmSthatWaynerq）Ortedse仕ledinitiallyandthenworsened
agamincludedhisftelingsofarHiousnessanddizziness．

4

2・1・3

ThecontentofDr・−，spatientfiledoesnotcontainWayne，shandwrittennote，

dated21StAugust2000，however，Iunderstandthatithasbeenenteredintotheevidence（EvidenceKohA12Tl）andthatitreadsasfo1lows：

No．

Content

StahlS

Consistentwith

30June2000（Synptoms）
1

Continuingdisequilibrium（especiallyfbel

2

Lethargyandfhtigue（stillthesame）

3a

Shortnessofbreath（littleimprovement）

Continumg

queasywhenwashingdishes，takingshower）

3b

Palpitations

New

Conthumg
Improved

Therapeutic e飴ct

Tolerance／

4

Eyesftellikethey

reswinHning（now，0nlyat

5

Legsfeelweak（theymomentarilycameright，

withdrawal

Improvedmomings）

Therapeutic

e薫ct

butnowcan，tseemtogetmuchstrengthinto

Improvedthen

Tolerance

Worsenedthem

6

Feeloutofkilter

Continulng

（0血eり

7

Summerlethargy

8Stress＆血tigue

9

Stiffshoulders

10

Hemorrhoidshaveworsened

11

Continuing

Improvedthen Worsened

UIcersinmouth≡︼1．−⁝・・1−鳥鼠圏・︼

12

Lostappetite

2・1・4

New

ToleranCe

Side−effbcts

Noimprovement

Tolerance

ThesymptomsinthishandwrittennoteareconsistentwithreportsfromWayneupon

PreSentationtoourservicesayingthatafterhisinitialsettlingofsymPtOmS，he

experiencedashortperiodoflittlechange，butfollowlng曲outl．5monthsof
Benzodiazepinebasedtreatment，henoticedthathehad‥（1）continuingsymPtOmS，（2）WOrSeningsymptomsand（3）somenewsymptomsaswell．

2・1・5

ThecontinulngOfsymptomsisapparentinnumbersl，2，6，8intheabovelist．

2・1・6

TheexceptlOnisthatthereappearedtobesomei叫prOVementin3a，4atthispomtin

time・NB：TolerancedoesnotalwaysformaCrOSSallsymptoms・

2・1・7

TheworsenlngOfsymptomsisapparentinnumbers5，9intheabovelist．

NB：AccordingtoDr・−spatient丘le，Wayne，simitialcornplaintofneckandback
Painhaddisappearedafterabout2weeksoftreatment（See？age8），buttheabovelist

SuggeStSthatthishadreturned・Wayne，sothercoⅡ皿entSaymgthatthefeelingof
Weaknessinhislegsmomentari1ycameright，butthenworsenedagainisofasimilar
Patteminthatitimprovedinitiallyandthenworsenedagain．

5

2・1・8Thedevelopmentof（notable）newsymPtOmSisqpparentinthelistingofHPalpitationsM．
InotethatthereisnopreviousmentionofthiseitherinWayne，shandwrittennotesorin
anyoftheotherpatient負Iespnor．

NB：IcanCOn丘mthatthisisconsistentwithwithdrawaltypesymPtOmS．

（2）FailureofDrugstoContainIllnessLongTerm

2・1・9ThefactthatWayneshowedaninidalsetdingofsymPtOmSfollowedbytheretumof
CertainothersymPtOmSalongwiththedevelopmentofnewsynvtoms（SeeArticles
2・1・3＆2・2・3）suggeststhathehadstartedtodeveloptheearlystagesoftoleranCe
followlngaboutl・5monthsofBenzodiazepinebasedtreatment，andsubsequently，thisShowsthatthedrugSWerenOtaChievingthedesiredresultofcontainingWayne，S

2・1・10IhwebeeninhrmedthatDr・1−isclaimingWaynehadmadeafullrecoyery？Sa
resultofhisdrugtreatmentwhJstunderhiscare・However，thePatientQuestlOnnalre

FormOnPage20fthet■MedicalCenhepaやt丘leshowsthatWa）meWaSStillSu蝕ringfromvarioussymptomsincludinghisonglnalcomplaintofdizziness（EvidenceKohA6），aSWaSthecチSeWhenhepresentedtoourserviceinApri12001．
2・1・11Takingintoconsiderationtheabove，andduetothefactthatWayneexperienced
Withdrawalsymptomsuponreduction（personallyobservedbymyself），WeCan
COnCludethathisbodyhadneuro−adq）tedandtherefore，WeCanalsoconcludethathe
haddevelopedtoleranCe．

Conclusion：WaynemeetstheDSM−IVTRcriteriaforHToleranCeH．
2．2

Withdrawal

2

．
一
．
︼
−
．
．
−導
．
︑
．
．
．．
．

塾塾垂墜垂望麺
1・WorseningoforiginalsymPtOmS（fiequency，intensity，nature）duringtreatment
2・Developmentofnewsy叩tOmSduringtreatment
3・WorseningofsymPtQmS（frequency，intensity，nature）uponreduction
4・DevelopmentofnewsymPtOmSuPOnreduction（1）WorseningofOriginalSymptomsI）uringTreatment（MuscleStifhess）

2・2・1TheworsenmgoforiginalsymPtOmSdurin拍eatmentwasapparentinthecomplaintof
musclestifhess・Wayne，shandwrittennote（EvidenceA12−1）showsthathe

芋三三三三三三i三三享三二三±王立

WaynebeganacourSeOfmassagesfromNovember2000atalocalphysiotherapyclinic
inSaitamatohelptryandalleviatethis．

2・2・2Wayne，shandwrittennote（EvidenceKohA26）showsthatthismusclesstifhesscame

toincludeasigni丘Canttighteninginhisjaw，Whichledtohimnotbeingabletoclose
hismouthproperlyfbllowlngabout4〜6monthsofBenzodiazq）ineprescnptions・6

AIsocontainedinthislistwasHpalnSinJOlntSH・Thisissupportedbythefactthatafter

retumingtoNewZealand，WayneconsultedtheDentalDepartmenthereatTaranaki
BaseHospitalandwasdiagnosedwithTemporoMandibularDisorder，OrTMD．

NB‥IntheQ＆Adocument，betweenMr・−andme，dated19thDeceqber2008，I
SaidthatIwasunabletocorr皿entfurtheronsomeofWayne，SsypptomslnCludingthe

musclestifhess・Thisisbecausefurtherinformationwasneededatthetimeinorderto

beabletomakeamoreoqectivedecision．However，nOWthatIhavehadthe
OPPO血nitytoviewthepatientmesfirsthand，andtoconsiderthisincontext，Ican
COn丘mthatthemusclestifhessisconsistentwithwithdrawal．

（2）DevelopmentofNewSymptomsDuringTreatment

2・2・3￣￣■〉▲一V〉〉⊥▲し、ノ⊥上目ノ日．
ThecontentofDrヽ■，spatientfile（Seepage29）h⊥ −DPaL⊥CllHI▲CtDCCPage∠ソ）SnOWStneIlrSt4SymPtOmS COntainedinWayne，shandwrittennote（EvidenceKohA26）assh bl

No．

content，OWn Status

eOW． Consistent with

NewSymPtOmS FromNovember，Startedtoexperiencelight1

18December2000
timitus（whentryingtosle印andupon

2

竺垂型垂ginthemomings） DevelopedwhatappearStObeasmearOnthe

3

4

NewepisodeNew

Withdrawal

Vitreous Opacities

lensofmyeyes（cataraCt？）（inrighteye，Canbe
SeeneVenaftereyeisclosed）FromOctober BecameSenSitivetoheat（bodytemperature
New

Side−ef托ct／ Withdrawal

SeemStOChangeallthetime） Pulserateishigherthanusual
New

5
6 7

Flusbes

New New

Startingtofbeldetached
Pressureinthechest
New
OccasionalstomachpainS
New
Lossinappetite

OmS

12

Side−e飴ct

New

Lossinsexualinterest DevelopedhabitofcloslngeyeSallthetime

8
9
10
11

New

Or

O

Noimprovement

O

ne

S●d

Withdrawal

Side−effbct／

W

h・

・

PahhJaWNew

13 Oftengotmouthabrasionsdmingchildhood 0ftensufftredfrommotionsicknessduring childhood PainSinJOlntS IsmokedmarUuanabetween15and21andWithdrawal

14
15

16

New

Withdrawal

expenencedasenseofparanoiaforatime

See血iclel．2．3
Of丘rst17

LostlOkilosinweight

18l

Insideofheadtwitchesandpulsates

19

report）

OncehadallerglCreaCtiontoTigerBalmand

developedanettlerash
7

Noim

PrOVement

01m

m

P

Withdrawal

Withdrawal？
Vement′PB：Iunderstandthattheabovehandwri

ennotewasinitiallygiventoDr．−。nlylnPartialformOn25也December2000atWayne，sfinalconsultation．Ihavebeen

informedthat，although，WaynecomplainedofallthesesymPtOmSVefbally，hedecided

toaddtothepartialversionofthelistwhilstwaitinginthewaitingroomwiththe

慧霊慧慧篭烹悪霊㌫慧慧霊慧蒜霊。Wthe
COmPletedlisttoDr・『』■asintended，andthatheshoweditt。Dr．lL。n22nd

January2001instead．

2・2・4

SymPtOmSOfinterestintheabovelistinclude；timitus，SenSitivetoheat

OlyPerSenSitivity），Pulserate（tachycardia），flushes｝lossinseXualinterest，feelin甲Of

detaclment（emotionalanaeSthesia），PreSSureinchest，OCCaSlOnalstomachpains，JaW
Paln，JOlntPalnS・Thecontentofallthepreviouspatientfilescon丘mthatWaynedid

nothavethesesymPtOmSPnOrtOCOmmenCingtheBenzodiazq）lnereglme．These
SymPtOmSareCOnSistentwithwithdrawaltypesymptomsand／orside−efftcts．

2・2・5TheonlysymPtOmB・Om（2・2・4）abovethatWaynehadpriortocoⅡ皿enCinEthel￣ヽBenzodiazeplnereglmeWaStimitus．Thecontentofthe

ENTpatientfileshowsthatWaynecomplainedoftimi1
attackinMay2000（page12）・HoweYPr，Waynereports

Hospital

hisinitialvertigo

thatthishadrectifieditself
beforehis丘rstconsultationwithDr・義■云n30也June2000，聖hissuppo正edby
t

′ヽ

1

▼

■・−■

thefactthattherewasnomentionofitagaln，eitherinWayne，sinitialhandwritten

notestoDr・−，OrindeedinDr．−，spatientfileeithe，．

2・2・6Thefactthattimitusdevelopedforasecondtime，following4〜6monthsof
Benzodiazepines，isonceagainconsistentwithwithdrawaltypesymptoms・Symptom
escape（wheresymPtOmSOftheoriginalcomplaintresurfaceduetotoleranceandlost
drugefftct）mayalsobesuggestive．

2・2・7Thesymptomsthatwereconsistentwithwithdrawalandfhstdevelopedduringthe
COurSeOfWayne，streatmentweremostlikelysecondarytothedevelopmentof

tolerance・Asmentionedinmysecondreport，however，itismostlikelythatWayne，sCOnditionwasduetoacombinadonofthesewithdrawalsymPtOmStOgetherwithotheradverseeffbcts，OrSymPtOmClusters，WhichiscoⅡ皿OninBenzodiazqpinedependence．
ThisissuppoltedbyProfbssorAshton，Whostatesthefollowlng‥

勒e乃わJerα乃Ce滋泥如HwfgああWα′＝即77軍わ乃7∫Cα乃WeαreVe乃血び釦ゐe脚

CO乃め㍑e∫わぬ鹿鮎あg・乃揖娩e即砂0乃び∫娩re物〝7αりわ乃㌢細川∫椚αreα〃血㍑re好めeJTe的相続e訪岬α乃d′加地血Wα′〝娩C怨加わわた和乃Ce．M（SeeBenzodiazeplneS：HowTheyWorkandHowtoWthdrawal・Pro￡C．H．Ashton．
RevisedAugust2002−Chapter2，Pages2／100fonlineversion）．

2・2・8Furthertomysecondr甲叫dated23rdDecember2008（whichfocusedmainlyonthe

POSSibilityofbreakthroughwithdrawalsymPtOmSOCCurringduringtreatmentdueto

慧謡等革帯慧畿憲法芸慧認ns
言霊慧芸悪霊慧慧恕慧芸㌔ay
notexertthesameefRct，eVenifitproducesthesameplasmaIevels．
8

（3）WorseningofSymptomsUponReduction

2・2・9Asmentionedinmy丘rstreport，Waynemetthecriteriaforwithdrawal，Whichwas
madeevidentbythefollowlngS匹ptOmS・Someofthese丘rstemergedduringthe
COurSPOfhistreatment（SeeArticle2・2・3）duetotoleranceandothersappearedforthe

鮎sttlmeOnreductionofhisoveralldose：

No．

1

Content

StatusConsistent

2
TlngllngSenSatlOnOVer hce Lossihcoordination
Newuponreduction NewuponredllCtion
3
MyoclonlCjerks
4 5

6Oilysmellinbodyodour （hcreased hypersensitivity） hwith

Newuponreduction
Withdrawal
Wlthdrawal

Newuponreduction

Wlthdrawal Withdrawal

CreaSedJOlntPalnS Tighteningofmuscles
Newdtnngtreatmentthenworsened
uponreduction
Withdrawal
hitlallylmPrOVed，thenworseneddming
treatmentandagalnuPOnreduction hitiallyimproved，thenworseneddming
treatmentandaainuo・dWithdrawal

7

WorsenlngOfdizziness8

WorsenlngOfpulsating temporalarteries

9Worsemngofvisual distl止bances

10 hcre￣aseinemotional instability

11

Wi血drawal

gPnleuCt10n hitiallyimproved，thenworseneddming treatmentandaainu d．

gPOnreuctlOn 址tiallyimproved，thenworseneddming treatmentandaainu

gPOnreuctlOn htiallyimproved，thenworsenedduring treatmentandagainuonreduction Newduringtreatmentthenworsened uponreduction

hcreasedpalpitationsd

Withdrawal

Withdrawal

Withdrawal

12 13 Tighteninginchest Flushng Newdmingtreatmentthenworsened uponreduction

Withdrawal

Newdunngtreatmentthenworsened uponreduction
yPerSenSltlVlty

Withdrawal

Initlallyimproved，thenworsenedduring treatmentandagainuponreduction

Withdrawal
Ⅵqthdrawal

2・2・10WorseningofsymPtOmS（ffequency，intensity，nature）vonreductionisapparentin

numbers5〜14intheabovelist，aSeXPlainedbelow．

（5・IncreasedJointPains，6・TightemingofMuscles）
2・2・11FurthertoArticles2・2・1〜3above／pg170fmy丘rstr甲Ort，aGPrecorrmendedthathe

undergoacourseofacupuncturetohelpassistwiththeadditionalmusclestifhessthat
hewasexperiencinguponreductionwithDr・JolmYuan（EvidenceKohCl0−3）．

9（7・WorseningofDizziness，8・WorseningofPulsating）

2・2・12Furthertopage170fmy丘rstreport，SOmeOfthefirstsymPtOmStOWOrSenupon
reductionincludedtheworsenmgindizzinessandpulsatinglntemPleareas．

NB‥ThisisconsistentwithDrJ，sobservationduringWayne，S2ndblanned）attemptatreductiononlStMarch2001（SeepagelOofJ−patientme）．

（9・WorseningofVisualDisturbanCeS）

2・2・13Furthertopage190fmynrstrqport，Waynewasconcemedabouthisworsenmgof
Visualdistufbances，andsubsequently，uPOnOuradvicehearrangedafollow−uP

examinationwithOphthalmologist＞Dr・KevinTaylor，Whosuggestedthatthestaggered

VisionmayhavebeenduetotheBenzodiazeplneSSlowingdownVisualsignalstothe
brain．

（10・hcreaseinEmotionalhstability）

2・2・14Fu血ertopage170fmyarstrepon，WereferredWayneontoclimicalPsychologlSt，
AlanGuy，forperiodicconsultationsregardingtheincreaseinemionalstabilitythat
hewasexperiencinguponreduction（EvidenceKohA18）．

（11・hcreasedPalpitations，12・TighteninginChest，13・Flushing）

2・2・15Furthertopage130fmyfirstr印Ort，Waynecom画nedthatthesesymPtOmS，Which
Lrstdevelopeddmingthetreatment（SeeA血les2・1・3＆2・2・3），WOrSenedagainupon
reduction．

（14・Hypersensitivity）

2・2・16Furthertopage130fmyfirstreport，Waynecomplainedofanincreaseinsensitivityto
lightandsoundduringthereductionprocess・Wayner甲OrtSthatheoftenfoundTV

PrOgramSWithvisualefftctstoooverwhelmingandthesoundtooloudcomparedwith
Othernormalpeoplear0undhim．

（4）I）evelopmentofNewSymptomsuponReduction

2・2・17Developmentofnewsy叩tOmSIVOnreductionisapparentinnumbersl〜4inthe
abovelist，aSeXPlainedbelow．

（1・TinglingSensationoverFace）
2・2・18Asoutlinedonpage170fmyfirstrq）Ort，Wayneexperiencedatinglingsensationover
hisfaceuponreduction（Paresthesia）．

（2・LossinCoordination）

2・2・19Asoutlinedonpage170fmyfhstrepod，Wayneexperiencedalossincoordination，Whichisrelatedtoneuromotordysfunction・andincludedarmandhandmovements．

（3・MyoclonkJerb）
2・2・20Asoudinedonpage170fmyfirstreport，WayneeqeriencedmyoclonlCjerks，Whichis

aSymPtOmOfwithdrawalobservedinSomepeople・（SeeBenzodiaz甲ineWithdrawal：
AnUhfinishedStory・Pro￡C・H・Ashton・1984，Page9／130fonlineversion）．

10

（4・OilySmellinBodyOdour）
2・2・21Asoutlinedonpage170fmyBrstrepoh，Wayneexperiencedthesensationof
emanatinganOilysmellinhisbodyodor・Thiscanbeassociatedwithanincreasein
hypersensitivity，Wherepatkntsinwithdrawalexperienceaheightenedsensitivitytoall
SenSationsincludinghearing，Sight，tOuCh，taSteandsmell・（SeeBenzodiazepines：How

TheyWorkandHowtowithdrawal・Pro￡C・H・Ashton・RevisedAugust2002−
Chapter3，Pages7／220fonlineversion）．

2・2・22Asoutlinedabove，Wayneexperiencedtheworsemngoforiginalsymptomsandthe

developmentofnewsymPtOmS，Whichwereconsistentwithwithdrawal，bothduringthe
treatment（duetotolerance）andalsouponreductionatourservice．

Conclusion：WaynemeetstheDSM−ⅣTRcriteriaforHWithdrawalH．

2°3●1諾還諸悪誓設置憲等慧慧慧諾慧競誌，
Wayneaaemptedreducinghisintakefrom3to2timesaday＆omlStMarchwitha
follow−uPCOnSultationdirectlyaReron2ndMwch｝Whichwasprobablyscheduledto

2・3・2Thereisanentryon2ndMa血ecordingtheresultofthisatbmptdreduction，aS（S）Pulsationonhistemple（right−？notreadable）（0）Wonderingifdrugshouldbechangedto2times（sincethedizzinessishcreasing．）

2・3・3Thereisanotherentryinthepatient丘leon19也March，Whchreads；HTakesdrugs3

2●3●4撃慧監蓋詮
times／dayn．

2・3・5ThereisanOtherentryon19也M批hstatingHⅠ弧thinkhgofgohgoff（thedrugs）aAer

2・3・6ThssuppohsWayne，sstatementsayhgthdhemadea3rdunsuccessfulatbmptat

StOPPmginlateMarch2001aRerretumingtoNewzealand，butwasunabletodoso，
andsubsequently，SOughthelp倉omDr・Whitwellandlaterfromourservice．

Conclusion：WaynemeetstheDSM−ⅣTRcriteriaforHLossofControl

11

．

2−4

1慧諾慧霊蒜衰㌫慧芳dentBlesap

Patie血co血e

NB：ThissupportsWayne，sclaimthathewasstiuabletoworkinJapan，albeitonught
dudes，beforetheBenzodiazq31netreatmentbeganandduringtheearlystagesofthe

2・4・2TheletterfromDr・mtWeuShowsthatfouow血gmorethan6monthsof
Ben凱diazepmeexposure，Wayneendeduplnastatewherehewasunabletoworkat

allagainforaperiodexceedingoneyear（EvidenceKohA7）．
NB：Waynewasonlydeclared丘tenoughtoretumtoworkagainaRerthedrugShad

beenremovedandaRerhehadrecoveredftomtheimidalwithdrawalphaseofhis

2・4・3ThetwostatemenbsubmiuedbyWayne輔iends，EdwardTeUaandJosephTait（whoknewhimwellbefore，dmingandaRerhisdependencyproblem），ShowthatWaynewas

Su脆ringa蜘・Notedinthesestatementswereaggressive
tendencies；includinganincidentwhereWaynestoodupandmadeabusivecorrments

tOPaSSengersonashuttlebusinSeptehber2000andanotherwhenhebecame
aggressivetowardspatronsatacaf芭inlateNovember，Whichwassaidtobeoutof
Character（EvidenceKohA14＆15）．

2・4・4ThestatementsubⅡ血edbyWayne，smothershowsthathewasexperienclng

地幽・Notedinthisstatementwaswayne，Sinabihtytocomm血cate
PrOPerly（inawaythatwasnormallyexpected），inabilitytoconcentrate，eXtreme

mOOdinessandmoodswings，dq，reSSionetc・Waynereportsthatthisinstabihtycaused

hismothertakingupsmokingagainforthe触ttimeintwentyyearS，Whichmayalsoheh）tOgivesomeindicaddnofthepressurethathiscondidonwasplacingontheh
relationshipatthetime（EvidenceKohC4）．

2・4・5Wayne，sIStstatement（EvidenceKohA22）showsthathewasexperiencingd塾旦塾
withromance（Seepages12＆15）・Notedinthisstatementwaswayne，slossinsexualinteresbhhtendencytosayhurtfu1thingsandsubsequentargumentswithhhgirlfriend

at也e血e伽・
NB：Wayne，shandwri

ennote（EvidenceKohA26）alsonotescontainslossinsexual

2・4・6Wayne，S2出statement（EvidenceKohA30）showsthathewasexperiencinga
SignifiCantreducdoninhisabihtytotakepartinrecreadonalactivities．Notedinthis

StatementwasthereluctanceofalocalgymtOallowWaynetobecomeamember
becausehewasstinwalkinglikeadrunkandsometimeshadtosuppo托himselfby

holdingontothings（SeeA血cles22＆25）．
NB：ConsideringthatWaynewasexperiencingdifncultyinwalking，thesocial
PrOblemsoutlinedabove，andthathewassu飴ringfrombothphysicaland
PSyChologiCalSymPtOmS，itseemsreasonabletoconcludethathewasalsoexperiencmg

alossinhisabilitytotakepartinnomalactivities．

12

2・4・7Asoudinedabove，Wayneexperiencediqairmentonhisabihtytowork，lossinabihty
tOSOCialize，relationshipdifnculdes，difficultieswithromanCe，andareductioninhis

abihtytotakepartinrecreadonalacdvides−ShowingasigmiLcantimpactonhislife．

Conclusion：WaynemeetstheDSM−IVTRcriteriaforHⅠ叩aCtOnLife門．

2・5

辿−UseDe亭軸

2・5・l ThecontentofPr・−spadent丘leshowsthatWaynewasthetype。f，e，S。nWh。

ShowedanongolngaWareneSSOfhhcondition・Thisisapparentinhishandw血ennotes，

bothathstpresentadonanddmingthecourseoftheheatment（Seepagesll〜13，29）．

2・5・2Thecontentofthe￣￣：￣￣￣￣二▼Padent丘leshowsthatWaynereturnedt。the
NeurologyD甲artmentseekingare−r血raltoanotherhospitalinthequestfor

alternadvetreatmenLThiskconsistentwithshowingawarenessthatthedrugtreatment
underDr・−mayhavebeencausinghimharm．

NB＝Thetime＆ameOfthisre−referralrequest（13thDec2000）coincideswithWayne，S肋rq）Ohed紙emptatreducdonOateNovembeOandhishandw血nnote（18也Dec

2000），Whichalloccu汀edwithinabout3Weeksofonean0ther．

2●5●3慧詔憲憑豊吉芸農だ憲認識≡；鵠誓to
2・5・4ThecontmtofthetヽMedicalCenhepadent丘1eshowsthatWayneandDr−had
negOdatedareducdonplan・haccordanCewiththisplanWayneaaemptedreducing

禦禦禦表莞艶貝卿
Conclusion：WaynemeetstheDSM−IVTRcriteriaforHContinuedUseDesplte
KnowledgeofHarm．

13

SectionThree

3．1Recover

3・1・l Wayne，srecoverywasmadeapparentbythefollowlng：

1・Recoveryfromsynq）tOmS

2・AbilitytoretumtOWOrk
3・Abilitytoretumtorecreationalactivities

4・AbilitytoretumtoJapan（1）Recovery蝕・OmSymptoms

3・1・2Asoutlinedonpage120fmy丘rstrq，Ort，WaynerecoveredfrommostofhissymPtOmS
WithinthefirstyearofcessationwithmanySymPtOmSSubsidingwithinthefirst3monthS．
NB：Waynedidcontinuetosu脆rfrompanicattacks，however，thisneedstobeanalyzed
takingintoconsiderationthelongtermefftctsincluding；PrOtraCtedwithdrawal，thetraumaof
thedq，endenceexperience，andtheadditionalpressuresofhissubsequentcasefor
COmPenSation．

（2）AbilitytoRettlrntOWork
3・1・3

Dr・mtWelldeclaredWaynefitenoughtoreturntoworkinJune2002（SeeEvidenceKoh

A7）・Afterbeingdeclared丘tenoughtoretumtOWOrk，WaynewotkedasanEnglishteacher

forQueen，sAcademyofEnglishforlyear（SeeEvidenceKohC5−2）．
3・1・4AfterendingtheaboveemploymentCOntraCt，WaynebeganWOrkingasayardmanfor
Placemakersforlyear・ThisjobinvoIvedhandlingbulkbuildingsuppliessuchastimber，Cement，bricksetc（SeeEvidenceKohC5−4）．

3・1・5WaynealsoworkedasanadventuretourguideforAncklandAdventures・Thisjobinvolved
fulldayhikingtours，CanOelng，SnOrkeling，horseriding，mOuntainbiking，PrOlongedhoursof

driVingetc（SeeEvidenceKohC5−7−2−蔓1）．

NB：Although，Waynewasabletomakearetumtoernployment，Iunderstandhehasbeen

limitedinhiscapacitytotakeonjobsthatinvoIvetoomuchresponsibilityduetothepanic
attacksmentionedabove，WhichwasoutlinedinPsychologist，AlanGuy，sletter，dated27也

Apri12007（SeeEvidenceKohA18）．

（3）AbilitytoReturntoRecreationalActivities

3・1・6Wayme，sabilitytoretumtorecreationalactivitieswasmadeapparentinArticle3．1．5above．

3・1・7FollowingthereluctanceofalocalgymtOallowWayneamembershipin2001（afterheenteredtheirtrainingfacilityinanaPParentStateOfpoorhealth）WaynebeganaPhysicaltrainingprogram，Whichovertimeresultedinsignificantgaipsinweight，StrengthandStamina・Thisissupportedbythefactthathewasabletomalntainhiscapacitytoworkasan
adventuretOurguideandyardmanOutlinedabove．

14

（4）AbilitytoReturntoJapan

3・1・8Wayne，srecoverywasmadefurtherapparentbyhiscapacitytoretumtOJapan，Whichwas

踪謡濫荒認諾誤琵悪霊盃outlinedin
3・1・9InsuⅡmaryOftheabove，Wayne，sconditionuponpresentationtoourservicewassuchthat

hewasunabletoworkandwassufftringfromarangeofphysicalandmentalsymPtOmSWith
Obviousweightlossandlossinstrength・Incomparison，followingthecomplet血ofhis
reductionprogramatourservice，hewasabletomakearetumtObothworkandrecreational
activities・Fbrther，hewasabletoretumtOJapanOnCeagalntOliveandwork，anddesplte

beingundermuchgreaterstresstherenowwithhiscurrentclaimforcompensation，Ⅰunderstandthathecontinuestomaintainamuchbetterstateofhealthatthispresenttime．

3・2塾亜shPrescnpti些旦旦墜道
3・2・lIunderstandthattherehavebeensomediscrq）anCiesregardingtheapparentshortfallsin
PreSCriptiondoses・Also，Ihavebeeninformedthatadecisionwasmadesuggestingthat
becauseoftheseshortfalls（particularlyinNovember2000，Whentherewasashortfallof
about15doses／5daysworth）Waynemusthavehadtheabilitytomissconsecutivedoses，andtherefore，COuldnothavebeeninastateofdq）endence．

3・2・2However，inaccordancewithourdiagnosis，theoverallclimicalpicture，andtheapplicationof

theDSMⅣ−TR，WeknowthatWaynewasdefiantlydependent．
3・2・3InordertohelpclarifythepotentialforWaynetohavemadeitthroughthetermofhis

慧諾霊；票蒜3g三ぎ；霊票霊箪慧確認e
2000and2001，WhichIhavehadtheopportmitytoview・Also，uPOnfurtherconsultation
WithWayne，WeWereabletoidentifythefollowingpossibilitiesregardingtheshortfalls．

1・ThepossibilitythatWaynecommencedhisprescriptionsincrementally．
2・Thepossibilitythatthereweredosagesurpluses倉ompreviousprescriptions，aStherewas

inAugust2000（6doses）．
3・Thepossibnitythatadosagesurpluswasaccruedduringtheeadystages，duetoforgomendoses，WhichisnotunCOmmOnincasesoflongtermtreatment（however，Wayne，sability
tomissdoseswouldhavedecreasedwithtimeashisdqpendencyprogressed）．
4・Leftoverdosesfiomattemptsatreduction，aSWayner印OrtSWaSthecaseinNovember．

3・2・4ARerconsideringtheabove，Icanconhthatitwouldhavebeenpossibleformyneto
havemadeitthroughthedurationofhisheatment，despitetherebeingapparentshortfalls，anddespitethefacthewasdq）endent，bywayofaccrulngareserveSurPlus．

3・2・5GiventhatWaynemeet50utOfthe7CriteriaoftheDSMⅣ−TR，andgiventhatitwas
POSSibleforhimtohavemadeitthroughthetreatment｝despitetherebeingapparentshortfalls

indoses，thisargumentdoesnotformgrOundsforru1ingoutdependence．

15

3・3⊇裏塗re頭姐地由nxietydisorder）
3・3・1ⅠunderstandthatWaynewasdiagnosedwith

AutonomicNervOuSDisorde（，byDr．、atthe−MeucalCenter，WhichIhave？eeninformedisatermCOmmOnlyusedinJapanFO
describethesu飴ringofpsychosomahcsymPtOmSCauSedbygeneralhftstresses／anxlety・

3・3・2Ⅰalsounderstandthattherearetwopartstotheanxietydisorderargumentasfouows：l・ThatWaynewassu脆ringfromsymPtOmSaSSOCiatedwithstress．
2・ThatWaynewas声u飴ringftomsymPtOmSaSSOCiatedwithachronicanXietydisorder．

Beforeaddressingeachofthese，Iwouldliketoclarifytheteminologiesbelow．
3・3・3Generally，inEnghshspeakingcountries，Wedonotusetheterm

AntonomicNervOu？

DisordeP，todescribepsychosomadcsymPtOmSCauSedbygenerallifestressesor狐lety

COndidons・ItismorecoⅡ皿OntOuSethetermHA血ety

・Asnotedin

Managementof

MentalDisordersfourtheditionMOhbhshedbyWorldHealthOrganization）・

Theexperience

OfanxietyisverynormalqmoderatelevelsofanxietywiuimproveperfbrmanCeandevenhighlevelsofanxietywiubeapTOPriatewhentheyareconsistentwiththedemandsofthe
Situadon…・hdividualSwithametydisordershavespeci丘candrecurringftarSthatthey
recogmzeasbeinglrrationalorunrealisticandintruSive．M

3・3・4Subsequendy，inmakingthisdiffhtialdiagnosis，IhavechosentousethetermHA血ety
Disordef，toincludetherangeOfdisordersoutlinedintheDSMIVandalsodehedbyWTIO．
Theseinclude：Panicdisorder，Agoraphobia，Socialphobia，SPeCificphobia，Generalised
anxietydisorder，Obsessivecompulsivedisorder，POSttraunaticstressdisorder，aCuteStreSS

disorder，anXietydisorderduetoageneralmedicalcondition，anXietydisordernototherwise
SPeCified，aquStmentdisorder｝uneXPlainedsomaticcorppla血Sandhypochondriacaldisorder．

3・3・5InWayne，scaseIhaveexcludedsubstanceinducedanxietydisorderbecauseanyanxiety

SymPtOmSWaynepotentiallysbffbredfromdmingthecourseofhistreatmentin2000〜200l
Werelikelytobesecondarytothemedicationhewasprescribed．

3・3・6Waynehasalwaysmadeitclearthathehadstresssymptomsduetoastressfuljobin

襲撃琵莞濫造窺轟転，。毎Shortnessofbreath，althoughtherewasnomendonofsweatypalmSandracing／sc抽ered

3・3・7Waynerq？OnedtoourservicethatmostofthesestresssymPtOmSdisqppearedaRerchanglng

jobsattheendofMarCh200P・However，theredoesnotappeartObeanythingintheI−『−HospitalENTpahentfuetosupportthis，althoughhedidsayonpage13thathe
reallylikedhisnewjob・HealsosaidthatheftltabittiredfromtheBrstmonth，straimig．hPardcular，hebecameabitwoozyaroundthemiddleofApri1・Ⅰamunabletocommentasto

Whetherthiswoozinesswasrelatedtothestressofhispreviousjoborwhethertherewasa
SeparateCauSe．

16

3・3・8

Basedontheabove，WemuStalsoconsiderthepossibilitythatWaynedidnotrecover

磁慧監禁言霊慧ntionedstresssymPtOmSbeforecomencinghstreatmedunder
3・3・9Inadditiontotheal，OVeStreSSrelatedsymPtOmS，Waynehasalwaysmadeitclearthathehad

feelingsofanXiousnessovernotbeingabletoreceiveacleardiagnosisfbrhisvertigoattack
onllthMay2000andsubsequentbalanCePrOblemthereafter．

3・3・10However，itmustbemadeclearthatevenifWaynestillhadthestresssymPtOmS・relatingto
hisformerjobandanxiousnessovernotknOwingwhatcausedhisvertlgOattaCk，thepresence
OfthesesymPtOmSdonotdetract丘omthefactthattoleranCe，Withdrawalanddependency

WereformedforthereasonsoutlinedintheDSMIV−TRabove．

（2）ChronicAnxietyDisorder三三￣二二王三三笑三章三三三三三三三三三三三三Chronicinherentamietydisorder，aSOPPOSedtodependency・

3・3・12BelowareindicatorstosuggestthatWaynedidnothaveaninherentchronicanXietydisorder：

1・Noprevioushistoryofpsychologicalorneurologicalcomplaints，aSeXPlainedinDr．ter

Haar

sletter（EvidenceKohA19）andDr・AlanGuy，sletter（EvidenceKohA18）

2・Nonotal，lehistoryofmedicalcomplaintswhilstlivinginJapanfor3yearspnorto1999
3・hitialtestinganddiagnosesinJapandidnotindicateananXietydisorder

4・AnxietydisorderoTlydiagnosedaRerBenzodiazq3ineexposure，aSOutlinedinthe『『■MedicalCenterpatlent丘le（EvidenceKohA6）
5・Firstdevelopedmentalinstability0nlyafterBenzodiazepineevosure−includingpmic
attacks，anXiety，depression，mOOdswings，aggreSSion，COnfusion，feelingsofgoingmad
6・Therewasnoapparentincreaseinstressfuleventsduringthecourseoftreatment（apartfbmthefacthisconditionwasworseningandhedidnotknowwhy）
7・WasdeclaredunfittoworkonlyafterBenzodiaz印meeXPOSure，aSOutlinedinDr．
Whitwellsletter（EvidenceKohA7）

8・ConditionimprovedfollowingPOmPletionofinitialwithdrawalphase（SeeArticle3．1）
9・CurrentlyresidinginJapanagalnandundermorestressnowwithcourtproceedings，butmaintainingbetterhealth

17

（3）

OtherConsiderations（SymptomEscape）
3．3．13Itcouldbearguedthatthe

retuming／worseningof占ymptoms，dmingthetreatment（A血cle

2．1．3）wasduetosymptomescape（wheresymPtOmSOftheoriginalcomplaintresurface）・
However，SymPtOmeSCaPealsooccursasaresultoftoleranceandlostdrugeffbctand

therefore，thisargumentdoesnotdetractfromthecriteriaoftoleranCehavingbeenmet・（IlhessProgression）

3．3．14Itcouldbearguedthatthe

newsymPtOmS

duringthetreatment（Article2・2・3）wereduetoillnessprogression・However，Whenputintocontextoftheoverallclinicalpicture，itbecomesapparentthattheyweremostlikelyduetowithdrawal，aSeXPlainedbelow‥
1．Therewasnoapparentincreaseinstressfuleventsduringthecourseoftreatment

2・ThesenewsymPtOmSWOrSenedagainduringthereductionprogram（syrpptomrebound）

andthentheyalleventuallyeasedofgdisappearedonceallBenzodiazeplnePreSCribing
wasceased．

3．ThesenewsymPtOmSWereaCCOmPamiedbyothernewwithdrawalsymPtOmSduringthe
reductionprogram，Whichalsoeventuallyeasedoff／disappearedonceallBenzodiazeplne

PreSCribingwasceased．
NB：TheexceptlOntOSymptOmSimprovlngafterthedrugSWereCeaSedwasthepanicattacks，
whichIunderstandhavecontimedonandofftoalesserdegree，WhilstimprovlngOVertime．

Withregardstothepanicattacks，WemuStalsotakeintoconsiderationthelongtermeffbcts

includingprotractedwithdrawalsyndrome，thetraumaofthedependenceexperience，andthe
additionalpressuresofthesubsequentcaseforcompensation・

PependencyCanProduceAnxietySymPtOmS）
3．3．15Furthertotheabove，WemuStalsoconsiderthatdependencycanPrOducetheverysymPtOmS
theyaredesignedtotreat，i．e．anXietysymPtOmS，aSnOtedbyProfessorAshtonbasedona
Clinicalstudybelow．

望由か甲0∫∫剃eわ∫呼1〃ゐe伽r娩eprevわ以ゆ呼pαre乃砂∫fαあお卯だe乃怨WO以JdゐdVe
鹿ve呼edp叩C揖αかC即乃甲07びわ虎eα如e乃Ceq揮e乃ZOddZ甲乃egre霊力e乃乙〃ever娩eeJ∫，

才力e〜乃地物peα相和Ceげ呼野加岱碑rァperわd折e騨Jαrあe乃ZO成αZ画乃e㍑略娩eカcf触αJJpがね乃出くわveJ呼ed∫加fJαr乎押野わ〃びZrre軍eCかeげ娩epWCゐ加rk旭fo叩，α乃dfゐe
加甲rOVeme加西erか㍑g・W油かαWαムαJJ∫喝ge∫f娩dffゐe乎〃甲わ〃びreg祝Jねdβ0乃7

e乃ZO粛αZ甲わe以∫eα乃d乃0タ0〝α乃以乃鹿ゆ加g（乃Jfe少乃e〟rO由．乃由VねW

αgdねo ee乃

e甲reβ∫ed砂上αdeれ7シrenα乃do娩em．
乃e呼peαrα乃Ceげ平〝甲加岱WゐfJe娩epα加地Were∫fgJJfαお乃gゐe乃ZO成dZ甲f乃郎∫祝gge∫などゐe
滋ve桓p乃e乃拍roerα乃Ce．砂〝甲わ〃7∫擁roわ乃ged混ざeαregα〜dfo加cJぴあわざ∫

オ

CO乃Ce乃かα才わ乃α乃d777g7770叩，ゐC肋ef乃p乎Cゐ0m0わrpeゆγ乃7α乃Ce，卸reg∫わ乃，α乃dem0才わ乃αJ

α乃αe∫娩びわ．椚班娩e鰐C甲如乃qrem0お門αJα乃αe∫娩e∫れWあわゐWα∫e窄erね乃Cedo頑′毎ごろe加0ク加わ乃ねWffゐα旭わツゲ卸re∫∫わ招，αJJpα鹿乃出血ve桓pedgあがejy乃卯O乃び．肋verfカeわざ∫，
Wゐ始めepα如花かCO乃血祝edわねおろe zo成dZ甲加e∫

ゐαゐogo eer〃〃fomJ

ぶ∫OC血ee ww班

あe乃ZO成α甲加ew肋励αWαト乃αmeかαg・わ也わ乃，pα乃わα伽C由，dgOr呼0ね，α〃〟C加αgO乃ぶ，
β㍑∫ゐ加島∫Weα加島gα∫加地e∫血αJゐ血rろα乃Ce∫，〃7揖CJepαわび，卯rαeggあおねe，α乃加7αアリ
0娩er∫．血∫eVerαCα∫e∫乃Creがed e乃ZOddZ甲乃eあぶαge

ten甲Ora77alleviationQftheSynq）tOmS．

αd ee乃pre∫Cr路edWf娩

（SeeBenzodiaz甲ineWithdrawal：AnUn丘血shed

Story．Prof二C．H．Ashton．1984，PagelO／130fonlineversion）．
18

（me−eXistingSymPtOmS）
3・3・16ItcouldbearguedthatmanyOfWayne

ssymPtOmSWerePre−eXistlngandweretherefbrenot

relatedtodependencyandwithdrawal；however，itisnotthatsimple・Thisisbecauseinthe
CaSeOfdependency，Pre−eXistlngSyrq）tOmSwilloftenchangeinnature，frequencyand

duration，Whichcanhelpustodi脆rentiatebetweentheonginalcomplaintandthe
developmentofwithdrawal．BelowareSOmeeXamPlesinWayne，scase．

3・3・17Musclesti臨leSS−WeknowthatWaynealreadyhadmusclestifhesstobegin，however，thisChangedinnaturebecause，aReritirnprovedinitially，itretumedandworsenedto−thedegree

thathisjawbeganlockingup，Whichissuggestiveofwithdrawal，aSObservedinaclinicalStudyconductedbyProfbssorAshtonbelow：？血7f乃Vα血揖pα佃げ加古0卸Wα叩rO乃−わe加入bcたpα加α房occ密細川eαゐC毎pα乃乃
fゐe肋血ゐCわあed郎αCあわ7＆あは相加＆Orα肋格α乃d印加如ゐe＿ねwwereαJJco椚刀70乃年頭

q触7錐Vere・肋町卯加地CO〝pJ血7edげ加紘ZC毎α扇∫0乃ほろd祝乃血瑠0乃eeズ加C如那げ
御〝e乃砂乃Or昭Jgee紘肋乃加わ∽pd加地αねoco〝甲山加edげ〝goo娩αCゐe．〝d〃即だe乃おαど∫0椚e∫喝eco汀pJαわ7edげαmefα〃わor以呼Jeα∫α乃才知はざ亘節ze∫∫α乃dweα肋e∫∫q塵型

αCCO乃坤お・升emOrげとゐe触れゐα乃dノの明朗d椚MCJe
J払C加わ如乃，pd摘αJαゆわ‖ゐef鋸g如，Were乃0ねd玩∫抑erαJpα加地Jm町CO乃甲われedげ

飽放た乃ノer短，卯摘αJαゆ加娩eねがhf∫Ome加甜q酔C血g娩e∫ゐ0ぴ地相α乃舶αCと肋OclonicierkswereobservedinseveralpatienLg．

（SeeBemdiazepineWithdrawal：AnUn丘dshedStory・Pro￡C・H・Ashton・1984，Page8−9／130fonlineversion）．

NB：AccordingtoWayne

smedicalrecordsPr・terHaar）Waynehadaprevioushistoryof

PeriOdiqlowerbackpainsincestraininghisbackli丘hgheavylumberinMarch1989andhealsohadahistoryofperiodiQneCkpain，WhchaccordingtoWayne，hstdevelopedinlate

1997whilstdoingprolongeddeskworkusingalaptopcornputerwithPoorergonomics（MiyazakiLocalGoveTmentOfnce）．
However，thenatureofWayne，smSClesti餓leSSfo110wing4〜6monthsofBenzodiazq）lne
PreSCriptionswasquitedi臨rentinnaturefromtheabove，aSWaynebegantOeXPerienceJaW

StifhessfortheBmttimetothedegreethathewasunabletoclosehismouthproperly・Further，WaynereportsthatthisⅡmClestifhess，Whichwaspreviouslylimitedtoperiodicq）isodesinthelowerbackandneckareaS，CametOenCOmpaSShisentirebodychanglngln
nature倉omperiodictoongolng・Waynerq，OrtSthathesubsequentlydevelopedthehabitof

massaginghisthighseveryeveningathome．

ThisissupportedbythefactthatWaynebeganaCOurSeOfregulardeqptissuemassage丘om

November2000atalocalphysiotherapyclimiCinSaitamatOhelptryandalleviatethis．Ihave

alsohadtheopporhmitytoviewanEnglishtranSCriptoftherefbrralformfromDrt■tothe
abovephysiotherapyclinicPSaitama膚−physiotherapyChnfc），Whichsays

basbeensu脆ringfromincreasl鱒muSCulartensionintheupperrearreglOnOfhisneckandshoulde摺り．

19

3・3・18HypersensitivityLWeknowthatWaynealreadyhadlightsensitivityfollowinghisvertigo
attack，however，thissensltlVltyChangedinnature叩OnWithdrawalbecauseWaynereports

thathefoundthevisuale脆ctsandvolumeofTVprogramsintolerablecomparedtoothernormalpeoplearOundhim・Further，thishypersensitivitycametoincludesensitivitytosmell，WhichwasapparentinthathesensedhewasemanatlnganOilysmellfiomhisbodyodor．
Thistypeofhypersensitivityissuggesdveofwithdrawal，aSObservedinaclinicalstudy

COnductedbyProfessorAshtonbelow：

ucαrαCおお如廓虎視req拍e彫Odα甲加ew戊d′αWα加東如e乃ed∫e乃通わ砂0αJJ∫e乃∫α如乃∫一点e∽7移∫夜毎加C九おおα乃如乃7e丑酌e乃α如乃喝ごろe∫e∫e那α如乃∫Cd乃ろe

竪琴等警姦窮藍

わびeC怨αreCrαW拓智OVer娩e吼肋畑地eco乃eα通路ねα乃d勉即鱒＿地物∫0頑草地吐肋町ク叩ねco〃画玩げα乃7eね批おge如ゐe777。緑地等慧恵恋慈恵稟藍，Revise。

August2002−Chapter3，Pages7／220fonlineversion）．

（Di脆rentiatingBetweenSymPtOmS）
3・3・19IthasbeenaskedhowwecandiffkentiatebetweensymPtOmSOftheoriginalcomplaintand
thoseofdependence・Admittedly，itcanbeverydifficulttodifftrentiatebetweenthesebecause，insomecases，thesymPtOmSareVerySimi1ar・Thisiswhyitisnotpossibletomake
anyjudgmentssimplybasedonanalyzingafewsymPtOmS・Rather，eVerythingneedstobe
COnSideredincontextincludingtheapplicationoftheDSMIV−TRcriteria．

3・3・20Generallyspeaking，ifthedrugSareaChievingthedesiredefhct，thepatient，sconditionwill
nodoubtimprove・hcasesofBenzodiazq，ined甲endence，thepadentwullikelyexperience
aninitialsetdingofsymptomsfollowedbysymptompa

ems？OnSistentwithtolerance（SeeArticle2・1）・Whenthisisthenfollowedbyacominualworsemngofsymptomsandthe
developmentofnewsymPtOmSduringthetre如ment，itissuggestiveofwithdrawal
SymPtOmS；ho竺eVer，illnessprogressionmustalsobeconsidered（See3・3・14）・Ifthepatient

experiencesanlntenSifyingofthesesymPtOmSuPOnreduction（SymPtOmrebound）together
withthedevelopmentofothernewwithdrawalsymptoms，itislikelythatthesymptomswere
duetodependence，aSWaSinWayne，scase．

3・3・21Further，WhenthesesymptompattemsarePutintocontextoftheoverallclinicalpicture（SeePageSll〜12，ReportOne）includingprescriptionhistory，theinabilitytoworkfollowingthe
treatmentandthentheabilitytoretumtoworkfollowlngdrugrehabilitationetc．andthe

applicationoftheDSMIV−TR（SeeSectionTwoabove）includingtheunSuCCeSSfula

empts

atreductionetc・itbecomesclearthattheworsemngofsymptomsanddevelopmentofnew

SymPtOmSdmingthecourseoftreatmentweremostlikelycausedbydependence．

（RelevanCeOfAnxietyDebate）
3・3・22Itmustbemadeclearthattheoutcomeofthedebateregardingwhetherornotwaynehadan
anxietydisorderdoesnotalterthefactthathewasBenzodiazepinedq）endent．

20

3・3・23AnxietydisordersandBenzodiazepinedependencecananddocoexistinsomecases．hdeedmanypeoplewhoareprescribedBenzodiazepinesdohaveanunderlyinganXietyrelated
COnditionandthisissometimeswhythedrugSarePreSCribedtobeginwith・However，aS
PreViouslymentioned，BenzodiazeplneSarehighlyaddictivedrugSandareOnlysuitablefor
treatmentlastingfornomorethanabouttwoweeksbecausetheyinturncanCauSeanXiety・

3●3●24慧慧慧蒜認諾葦諾農芸票認諾旭dBenzodiazepinesforanymorethanaboutb〜4weeksissusceptibletodevelopingtolerancelandwithdrawal，includingpeoplewithan甲etydisorders・Subsequently，thedebateover

WhetherornotWaynehadananXietydisorderdoesnotfomgroundsforru1ingoutthesecnteria．

3・4ConsistencyofPrevlOuSReports＆Evidence．

三二￣‥三三三三三三二三二三三≡三三三三三三三言三三三Patientfiles鮎Sthand，Iamabletocon丘血thefollowingwithregardstothesymPtOmS
historyoutlinedinSectionOnemyfirstreport：

1・Articlel・4・8isconヲistentwiththePaやentQuestionnaireFormonpage20fthet■■
MedicalCedrepatlentfile（Evidence混ohA6）．

2・A血clel・4・7isconsistentwithWayne

shandw血ennotetoDr・『−鱒videnceKoh

A26）．
3・Articlel・4・6isconsistentwithWayne

shandwrittennotetoDr・『｝■鰐videnceKohA12）．
4・A正clel・4・5wasbasedonWayne，srqortsthatheexperiencedanimitialsettlingof
SymPtOmS−thisissupportedbytheinitialimprovementofhismusclestifhessoutlined

OnPage80fDr・1■l■spatient缶le鱒videnceOtsuAl）・

5・Ardclel・4・4iscons！Stentwithpagel字OfDr・ヽlspadentme（EvidenceOtsu今1）・
6．A血clel・4・3isconsIStentwithasu叩arizedverslOnOfpagellofDr．『■■Spatlent
me，Wheremostofthesymptomsarebasicallydifftrentwordsforthesamething，i．e．
dizziness（EvidenceOtsuAl）．

7・A血clel・4・2wasbasedonWayne，sr印OrtSthatmostofhisworkrelatedstress

SymPtOmSOutlinedinA血clel・4・lmostlydisappearedafterhechangedjobsinApri1

2000（SeeArticles3・3・6〜3・3・10forc車nentsonthis）・
8・Articlel・4・lwasbasedonWayne，srq？OrtSthathewasexperienclngWOrkrelatedstress

誓聖0誓，聖ChACP聖t竺空thpqges12〜13＿？f＿thefile（SeeA血cles3・3・6〜3・3・10forcoⅡ皿enbonthis）．

：

rENTpatient

NB‥Thesesy叩tOmSCOntainedinSection萱OneofmyfirstrqportarealsoconsistentwithWaynespresentationtoourservice．

3・4・2Inotethattherewassomeadditionalinformationcontainedinthepatientfiles・However，
noneofthishasanyslgni丘cantbearlngOn・theapplicationoftheDSMⅣ−TRCriteriaorthe
dependencediagnosis．

21

3・4・3htheQ＆Adocunent，betweenMr・『■andme，dated19也December2008，Ⅰ．suggesteda
numberofpossiblemechanismsformostofWa）瓜e，ssymptomsoutlinedinsectlOnSl．4．6andl・4・70fmy丘rstreport，andIalsosaidthatIwasunabletocommentfurtheronsomeof

Wayne，ssymPtOmS・Thisisbecausefurtherinfomationwasneededatthetimeinordertobe
abletomakeamoreo句ectivedecision．

However，thefactthatmanyofthesesymPtOmSintensifiedduringthereductionprocessand

thefactthattheyareconsistentwithknownBenzodiazeplneSWithdrawalsymPtOmS，aSWell
asotheradverseeffbcts，OrBenzodiazeplneSymPtOmClusters，remainsunChanged・Please
notethatthesewerelistedaspossibilitiesonly，andasImentionedinmysecondreport，there

arenumerousclustersofsymPtOmS／syndromesrelatedtoBenzodiazeplneuSeincluding；tolerance，dq）endence，Withdrawal，SymPtOmeSCaPe，SymPtOmrebound，Side−e鮎ctsetc，and

itisusualforthemtooverlqpsomewhat．

3・5宣弛reRqPQrtSandpPossibleTesti喝
3・5・1Iunderstandthereare3maindisputesregardingWayne，sclaimforcompensation，aSfollows：
1．Dependence

2・hformedconsent＆monitoring
3・Longtemefftcts／damageS（FutureReports）

3・5・2Regarding（2）above，IunderstandthattheinformedconsentandmomitoringpartofWayne，sClaimwasrqectedattheinitialhearingonthegroundsthattherewasinsufncientevidence／argumentputforwardwithregardstothis・S止bsequently，Iamhappytoprovideareporton

informedconsentandmonito血gbasedonWayne，scaseinrelationtotheWorldHealthOrganization，sHGuidetogoodprescribing

・

3・5・3Regarding（3）above，Iunderstandthatthereisadisputeoverlongtermefftctswithregardsto
Wayne，spostdrugrehabilitationhistory・Subsequently，Iamhappytoprovideareporton

longtermeffbctsofBenzodiazeplneuSebasedonWayne，scase．

（PossibleTestimony）

3・5・4Withregardstomyavailabilityforapossibletestimony，IamhappytotraveltoJapanfora
COurtdate・However，theactualtimewiuhavetobecon丘medinadvancewithmyemployer，Whichwillrequ汀eSeVeralmonthsnoticeinadvanCe．

NB‥Ontopofhavingsubmittedseveralrqportsregarding（1）above，itispreferabletosubmit
reportsregarding（2）and（3）aboveaswellinadvanCeOfanyPOtentialhearingdate．

Thiswiuallowtimetogetallofthefactsstraightbasedontheevidenceinordertohelp
PrOVidethemostaccurateinformationpossible・Bydoingso，allpartieswillhavethe

OPPOrtmitytoviewthereasonmginadvance，andtherefore，beabletoprepareanyquestions

thattheymayhave，WhichIamhappytorespondto．

Also，Pleaseunderstandthatpreparingtheser印OrtStakestime，aSIalsohavework

COmitmentsatthehospitalandthereisalsotheneedtorelayinLbrmationbetweenwayne
andhislawyerbetweentwodi脆rentlanguages．

22SummativeConclusion

1）WayneshowedsignsofdevelopingtheearlystagesoftoleranCefollowingaboutl．5monthsof
treatment．

2）Thiswasfurthercompoundedbyseveralmoremonthsofdailydosing，afterwhich，Wayne

developedseveralmorenewsymptomsthatwereconsistentwithwithdrawalandtolerance（followingabout4〜6monthsofprescriptions）．
3）Itwasar0undthistimethatWayne

S鮎endsbeganVOicingtheirconcernsregardinghiswellbeing．

4）Feelingconcemedthathisconditionwasdeteriorating；WaynereportsthathetriedunSuCCeSSfullyto

StOPhisdruginhkeinlateNove血ber2000．

5）軍00na苧er聖チtte叩tWayneretum申tosee＿Dr・＿『■atth√￣￣二二￣Hospitalon13th

December2000torequestare−referraltoanotherhospital，ShowinganaWareneSSthatthedrugswere
POSSiblycausinghimharm．

6）WaynethenbegantOmakealistofnewsymPtOmS，dated18thDecember2000，SOthathecould
betterconveyhisconcemSwithregardstohisdeterioratingconditiontoDr・−ManyOfthe

SymPtOmSCOntainedinthislistwereconsistentwithwithdrawalduetotoleranCe．

7）Subsequently，WeCaneStimatethatWaymehadlikelydevelopedBenFOdiazepinedependence
followingabout4pJmonthsoftreatment，Whichbasedonstatistics，lSatyPicaltime丘amefordependencetoform（Seereferenceonpage130fR印OrtOne）．

8）SoonafterchanginghospitalS，areduptionplanwasnegotiatedwithDr・−haccordanCewiththisPlan，WaynemadeasecondunSuCCeSSfulattemptatreduction．

9）Followingthisattempt，WaynedecidedtoreturntoNewZealand，Wherefollowingan0ther
unSuCCeSSfulattemptatstopping，hesoughtproftssionalhelpfromourservice．

10）Dmingtheformalreductionprogram，hissymptomsintensi丘edagainalongwiththedevelopmentof

OtherwithdrawalSymPtOmS・11）WaynerecoveredfrommostofhissymPtOmSwithinabout3monthsofcompletingtheinitialwithdrawalphaseofthereductionprogram・0thersymPtOmStOOkuptolyeartorecoverfrom
graduallyimprovlngOVertime，WhichistSuggeStiveofaprotractedwithdrawalsyndrome・12）Fouowingcompledonofthereductionprogram，Wayn？WaSabletomakeagradualretumto
recreationalactivities，WherehemadesignificantgainslnW軸ht，Strengthandstamina，Whichwas

madeapparentbyhisabilitytoworkasanadventuretourguideandyardmam
13）HehassincebeenabletomakearetumtOlivingandworkinginJapan，anddespitebeingunder
COnSiderablemorestressonthisoccasionwithhisongolngCaSefbrcompensation，hecontimleStO

maintainamuchbetterstateofhealth．

2314）Ihavebeeninformedthatthereweresomequestionsraisedwithregardstowhat

dependence

actuallyis・Dependencedoesnotsimplyreftrtoastateinwhichpeople丘nditdifnculttostoptaking

thedrugS・Itisasevereillness，WhichcanreSultinconsiderablementalandphysicalsu脆ringforthe
Patient，POtentiallycausmgslgnificantdamagestotheirlivelihoodsincludingwork，familysociallift，

andgeneralwellbeing，aShighlightedbyProftssorAshtonbelow．

男e乃ZOdねg甲わーeWfJ加かαWdfgα詑Vereg肋弧mepα血咄Were祝∫以α妙βな如e乃e或q侮乃加地e耶e二÷三三∵∵三一≒≒干≒空≡±≡≡≠±≒≒≒げ娩eかow乃，gゐ叩α加地∫娩rco乃∫磁rαろJ叩匂岱如才αgWeJJα∫乃le乃ねJゐfr餌．
（SeeBenzodiazepineWithdrawal：AnUnfinishedStory・ProEC・H．Ashton．1984，Page12／130f
Onlineversion）．

15）Basedonthecontentofmypreviousreportsandafterhavinghadtheopportmitytoviewthepatient

files（evidence）firsthand，ⅠamabletoreconfirmthatWaynemeets5CriteriaoftheDSMIV＿TR．

24