Psychiatric Examination

Following are excerpts from the examination documentation.

Date of Birth : 11/22/88

Date of Evaluation : 9/17/08

Qualifications of the Examiner

The consultant is a licensed physician in the State of Florida, and is a diplomate of the American Board of Psychiatry and Neurology, and also is a diplomate of the American Board of Forensic Medicine and diplomate of the American Board of Disability Analysts.

Legal information

xxxxxxxxxx was arrested on March 18, 2008. He is charged with attempted murder. According to subject and his mother, xxxxxxxx xxxxxxx, he was scheduled to have a pretrial meeting.

Subject and his mother were interviewed on 9/17/08. They provided information regarding a variety of subjects, including the alleged assault incident of 3/18/08.

Summary / Impressions

I have performed an Independent Psychiatric Examination on Mr. xxxxx xxxxx. I have developed several impressions regarding Mr. xxxxxx. These impressions are based on the 9/17/08 examination of Mr. xxxxxxxx, interview of his mother and sister, review of medical reports, review of legal reports and my knowledge and training as a board certified psychiatrist for the past 19 years.

Mr. xxxxxxxx fulfills the DSM-4-TR criteria for several psychiatric diagnosis.

He fulfills the criteria for Bipolar Disorder. He has both manic and depressive symptoms and therefore fulfills the criteria for a mixed episode. The symptoms which Mr. xxxxxx has, that have fulfilled the criteria for Bipolar Disorder during the past year include: depressed mood, irritability, sleep disturbance, racing thoughts, significant weight loss and lack of appetite, fatigue, flight of ideas and distractibility.

Mr. xxxxxx has several risk factors which have predisposed him to develop Bipolar Disorder including a family history of Bipolar Disorder and a history of Attention-Deficit Disorder. Epidemiologic studies show that there is a 2-4 fold increased risk of developing Bipolar Disorder if a person first developed Attention-Deficit Disorder.

Mr. xxxxx fulfills the criteria for Attention-Deficit/Hyperactivity Disorder. He has predominantly inattentive symptoms and not hyperactive symptoms. The symptoms which Mr. xxxxxx have that fulfill the criteria for Attention-Deficit Disorder include: often fails to give close attention to details, often has difficulties sustaining attention in tasks, is often easily distracted by extraneous stimuli, appears apathetic or unmotivated, trouble sitting still, impulsivity, interrupts or intrudes on others and trouble listening to others when talking.

Mr. xxxxx also fulfills the criteria for Cannabis abuse by history. He states he is no longer using Cannabis. While Mr. xxxxxxh has used Cannabis for recreational purposes, it is my opinion that Mr. xxxx has also used Cannabis to reduce the various symptoms he has of Bipolar Disorder. This phenomenon is referred to as self-medication. Both Bipolar Disorder and Attention-Deficit Disorder are associated with a significant risk of self-medication.

Based on the results of the examination I have performed, it is my opinion that the use of Valium (a benzodiazepine medication) during the night prior to the alleged assault was an example of self-medication. The history provided by Mr. xxxxxx, as well as other sources of information support that Mr. xxxxx was unable to sleep and took Valium to help him get to sleep. Mr. xxxxxxxh also states that he took a few Soma pills (a muscle relaxant) to help him sleep the night prior to the alleged assault.

Mr. xxxxxx presented a history of taking Valium and Soma to get to sleep. He states that he has essentially no memory of the events which took place between the time he took the Valium and Soma and the time he was being examined by police offices in jail the next day. It is my opinion that Mr. xxxxxxh developed a side effect of benzodiazepine medications referred to as anterograde amnesia. Anterograde amnesia is defined as the inability to form memory after some type of event occurs. In this case, the event is the use of Valium at 40 plus milligrams, which is a high dose of this medication. The DSM-4-TR diagnosis which is consistent with anterograde amnesia is Amnestic Disorder due to combination of alcohol and benzodiazepines.

Various peer reviewed scientific articles provide support that Valium can produce anterograde amnesia. Examples of such articles include;

In the article, Benzodiazepines - Effects on Human Performance and Behavior, O.H. Drummer documents; "Benzodiazepines reduce concentration and cognition and also can produce amnesia...  Amnesia is caused by impairment in the acquisition of newly learned information into long-term episodic storage, and is called anterograde amnesia. Patients will often have no recall of events during the duration of drug action, or at best partial recall.

In the article, Addiction - Part 1: Benzodiazepines - Side Effects, Abuse Risk and Alternatives, Longo, L. M.D. and Johnson, B., M.D. document; "Benzodiazepines induce anterograde amnesia …  These specific amnestic effects appear to be separate from sedation. Episodic memory ( the remembering of recent events and the circumstances in which they occurred and their time sequences) is particularly impaired and more markedly so in heavy alcohol drinkers who also use benzodiazepines.

In the Physician's Desk Reference for Valium under the section, Adverse Reactions side effects can include; "Antegrade Amnesia may occur using therapeutic dosages, the risk increasing at higher dosages. Amnestic effects may be associated with inappropriate behavior."

The risk of developing anterograde amnesia increases substantially under certain circumstances. This includes combining alcohol and other sedative medications with benzodiazepines. Mr. xxxxxxx did combine Alcohol, Cannabis and possibly Soma with Valium. It is my opinion that this combination significantly increased the risk of anterograde amnesia. In addition, brain scans support that Mr. xxxxxx shows evidence of temporal lobe, frontal lobe and limbic dysfunction. Dysfunction of these important control areas of the brain increases the risk of Mr. xxxxxh developing anterograde amnesia.

In addition to producing anterograde amnesia, benzodiazepine medications can also produce a paradoxical state of aggression. Various peer reviewed scientific articles provide support that Valium can produce violent and aggressive behavior. This phenomenon is referred to as paradoxical aggression, since benzodiazepines usually produce sedation and relaxation. The DSM-4-TR diagnosis which is consistent with paradoxical aggression is Sedative, Hypnotic or Anxiolytic Intoxication. Examples of such articles include;

In the article, Benzodiazepines - Effects on Human Performance and Behavior, O.H. Drummer documents;

"A number of benzodiazepines can cause paradoxical aggression, particularly on provocation. Although these reactions are not common, they can produce disturbing changes when drugs are abused. This is caused by loss of inhibitions, similar to that seen in persons under the influence of ethanol. In extreme cases, subjects may not have any conscious control over their actions. … The combination of alcohol and therapeutic dosages of alprazolam (1 mg.) has been shown to increase aggressiveness in response to provocation in a competitive reaction time task in moderate social drinkers. This increase is greater than predicted, from alcohol and alprazolam alone, suggesting synergistic effects of this combination on behavioral control."

In the article, Addiction - Part 1: Benzodiazepines - Side Effects, Abuse Risk and Alternatives, Longo, L. M.D. and Johnson, B., M.D. document;

"Increased excitement, irritability, aggression, hostility and impulsivity may occur in some patients who take benzodiazepines. This paradoxical disinhibition may, in rare cases, result in attacks of rage or violence, or other indiscretionary or antisocial behaviors."

The risk of developing paradoxical aggressive and violent behavior increases substantially under certain circumstances. This includes combining alcohol and other sedative medications with benzodiazepines. Mr. xxxxh did combine alcohol, Cannabis and possibly Soma with Valium. It is my opinion that this combination significantly increased the risk of violent paradoxical behavior. In addition, brain scans support that Mr. xxxxxxxxxh shows evidence of temporal lobe, frontal lobe and limbic dysfunction. Dysfunction of these important control areas of the brain increases the risk of Mr. xxxxxxxxxx developing impulsive and violent behavior if the brain is disinhibited with drugs such as a combination of Valium, Alcohol and Cannabis.

In the Physician's Desk Reference for Valium under the section, Adverse Reactions side effects can include; "stimulation, restlessness, acute hyperexcited states, agitation, aggressiveness, irritability, rage… Inappropriate behavior and other adverse behavioral effects have been reported when using benzodiazepines."

It is my opinion that the alleged assault by Mr. xxxxxxwas a direct consequence of Valium and its combination with Alcohol and Cannabis in a person with brain dysfunction. It is my opinion that Mr. xxxxxx is not a danger to society and if he does not take benzodiazepine medications, he should not develop aggressive and violent behavior.

It is also my opinion that Mr. xxxxx should be treated for his various psychiatric disorders.

Mr. xxxxxh began treatment in a one year drug rehabilitation program called Teen Challenge. I strongly recommend that he enter this program (or a similar program), if available. I recommend that some form of urine drug screens be incorporated into his treatment to ensure that he is being compliant with his drug rehabilitation therapy.

I recommend that Mr. xxxxxxx be treated for his Bipolar Disorder with non-addictive mood stabilizer medications. I recommend he start on Lamictal at 100-200 mg. daily. In addition, if he continues to have difficulties sleeping, the addition of sedative antidepressants such as Trazodone or Mirtazapine can be added.

I also recommend some form of individual counseling to develop better coping skills, to assist with making better life decisions and to learn how to live with Bipolar Disorder in a healthy manner.

I declare that the information contained in this report and its attachments, if any, is true and correct to the best of my knowledge and belief, except as to information that I have indicated I have received from others. As to that information, I declare that the information accurately describes the information provided to me and, except as noted herein, that I believe it to be true.

I declare that the diagnosis, impressions and recommendations in this Psychiatric Report are all within a reasonable degree of medical certainty.

To see the resume of the expert associated with this case study, see the link below.