Dr. Muhammad - Independent Medical Opinion

I am sending you an independent opinion report on the Appellant with reference number Decision #1374474. I have carefully reviewed the documents and my opinion is independent of the reports submitted on him earlier. I requested the patient for a personal interview but the patient was not agreeable for this.

If you have any questions or concern about the attached report, please do not hesitate to contact me.

Background Information:

This 51 year old gentleman has a long history of emotional and mood related difficulties with reported previous diagnoses of depressive disorder, obsessive compulsive disorder and panic disorder. Apparently, he had suffered from panicky attacks of moderate severity with multiple recurrences. His other major problem was with Obsessive Compulsive Disorder. This disorder in general is characterized by persistent, upsetting thoughts and rituals to control the anxiety these thoughts produce. For example, "people obsessed with genus or dirt, may develop compulsion to wash their hands over and over again. If obsessed with intruders, they may lock and relock their doors many times before going to bed. Other common rituals are a need to repeatedly check things, touch things in a special way, count things. Some common obsessions include having frequent thoughts of violence and harming loved ones, preoccupation with order and symmetry and hoard unneeded items." It is not clear what type of recurring obsessive thoughts troubled the Appellant. He also had treatments in the past with little benefit and more side effects. There is a history of hospitalization with no details about the circumstances, outcome and follow up arrangements. Apparently, the Appellant has not complied with the medications and does not see any psychiatrist. The last time he was assessed in 2006 by Dr. A. Walsh. Upon contact, the patient refused to present for a clinical interview and expressed his disinterest in any sort of medical intervention or follow up.

In the past, the patient had taken Anafranil, Prozac and some other medications but details about the dosage, compliance and duration of treatment are not available. There is a family history anxiety disorder. No details about personal history are available except for the unemployed status and lack of vocational interests because of anxiety state.

Medically, he suffers from Asthma for which puffers are being used by him. His previous (2006) psychiatric assessment report indicates that he was coping with the present situation, anxiety was lessened but adaptive functioning was also diminished.

As the patient did not appear in person, therefore, comments on his current mental state examination are not given.

With respect to the board's specific queries, I am narrating the details in a sequence:

Is the Appellant unable to provide for his own maintenance?

Documentary evidence suggests this but there is also an indication of his previous employment even for a brief period. His curriculum vitae is indicative of his level of skills that he had acquired through attending courses. It is likely that in the absence of psychiatric treatment and follow up, his coping ability, cognition and motivation may have remained disturbed to an extent that would prevent him from entering into an employment. Under these circumstances, he may well be unable to provide for his own maintenance.

Based on the review of his documents, it appears that his multi-axial working diagnosis will be as under:

• Axis I: Anxiety Disorder NOS (not otherwise specified) code 300.00
  Obsessive Compulsive Disorder code: 300.3
• Axis II: Deferred
• Axis III: Asthma
• Axis IV: No stressors at present
• Axis V: 61-70

Age at which mental health problem started?

Documentary evidence indicates that the Appellant had never received a solo diagnosis of Obsessive Compulsive Disorder (OCD), it was rather depression, anxiety, phobia, panic disorder along with OCD. None of these disorders are permanent as these are amenable to treatment and regular follow up. I understand that the Appellant is not being followed up by any psychiatrist or is taking any psychotropic medication. Regarding OCD, it can be accompanied by eating disorders, other anxiety disorders or depression. It strikes men and women in roughly equal numbers and usually appears in childhood, adolescence, or early adulthood. One-third of adults with OCD develop symptoms as children and research indicates that it runs in families. It responds well to treatment with certain medications and/or exposure based psychotherapy. There are augmentation therapies as well as deep brain stimulation.

This illness can occur much before age 21 but there is no information of observations made about the Appellant's condition on his first psychiatric visit. The 1986 report by Dr. Jain mentions that 'the Appellant's illness was of eight years duration, that will make him 28 years of age, there is also a mention of phobia in crowded situation at age 17 which is not OCD but a different condition called 'Agoraphobia'. Dr. Vaughan-Jackson in his report described the condition as Chronic Major Depression and also described him as "intelligent fellow who can look after himself as regards ADL (Activities of Daily Living)". Though OCD can occur much before age 21, I do not see any solid evidence for the Appellant having contracted this illness before this age.

Any other information that would be of help?

Follow-up and consultation reports when the patient was first assessed by a psychiatrist, previous treatment record and history of hospitalization could have helped in assessment of this case but in the absence of such information, this can be just anecdotal.

This report is based on my independent opinion after reviewing the documents carefully.

Dr. Amin A. Muhammad's Qualifications:

M.B.B.S. 1984 Dow Medical College, Karachi, Pakistan

MRCPsych, Royal College of Psychiatrists, London (9339) FRCP, Royal College of Physicians of Ireland

Ph.D. Anglia University, England

MCPsychl The College of Psychiatry of Ireland

BCPsych (Board Certification in Psychiatry) Institute of Psychiatry/University of London

DPM Conjoint Board of Royal College of Surgeons and Physicians in Ireland

DCP (Diploma in Clinical Psychiatry) Conjoint Board of Royal College of Physicians & College of Surgeons - Ireland

MCPS College of Physicians & Surgeons, Pakistan