McDonell and Repatriation Commission
[2008] AATA 613
•15 July 2008
Administrative Appeals Tribunal
DECISION AND REASONS FOR DECISION [2008] AATA 613
ADMINISTRATIVE APPEALS TRIBUNAL )
) No N2006/131 &
N2006/894
VETERANS' APPEALS DIVISION ) Re TINO McDONELL Applicant
And
REPATRIATION COMMISSION
Respondent
DECISION
Tribunal Ms Robin Hunt, Senior Member
Dr John Campbell, MemberDate15 July 2008
PlaceSydney
Decision We set aside the reviewable decision, in part, finding the applicant does suffer war-caused xeroderma. We affirm the remainder of the decision that the applicant does suffer war-caused depressive disorder but not post traumatic stress disorder, alcohol dependence, irritable bowel syndrome and generalised anxiety disorder. We also remit the matter for assessment, if such an assessment has not already been done, with date of effect being 13 April 2004.
...................[Sgd]..................
Ms Robin Hunt
Senior Member
CATCHWORDS
VETERANS’ AFFAIRS – Veterans’ Entitlements Act – issue of diagnosis of current psychiatric disorders – issue of relationship of such disorders to service – decision under review affirmed in relation to psychiatric disorders – decision under review varied in relation to xeroderma, which is a war-caused disease – decision in relation to irritable bowel syndrome affirmed.
Veterans’ Entitlements Act 1986 ss 9, 14, 120, 120A
Statement of Principles concerning alcohol dependence and alcohol abuse No. 76 of 1998 (revoked)
Statement of Principles concerning alcohol dependence and alcohol abuse No. 17 of 2008
Statement of Principles concerning anxiety disorder No. 1 of 2000 (revoked)
Statement of Principles concerning anxiety disorder No. 101 of 2007
Statement of Principles concerning depressive disorder No. 58 of 1998
Statement of Principles concerning depressive disorder No. 27 of 2008
Statement of Principles concerning irritable bowel syndrome No. 103 of 1996
Statement of Principles concerning irritable bowel syndrome No. 104 of 1996
Lees v Repatriation Commission (2002) 125 FCR 331
White v Repatriation Commission (2004) 39 AAR 67
Woodward v Repatriation Commission (2003) 131 FCR 473
REASONS FOR DECISION
15 July 2008 Ms Robin Hunt, Senior Member
Dr John Campbell, Membersummary
1. Mr Tino McDonell is a veteran, aged 58, who served in the Royal Australian Navy between 6 May 1967 and 5 May 1976. Mr McDonell had two periods of operational service, namely 14 May 1969 until 25 May 1969 and 1 November 1972 until 30 November 1972. Mr McDonell had a period of defence service from 7 December 1972 until 5 May 1976.
2. Mr McDonell lodged an informal claim for a disability pension on 13 July 2004 in which he claimed poor hearing, irritable bowel, chest problems, asthma, stress and nerves, diabetes, dry skin, and solar skin damage, together with poor eyesight. This was followed up by a formal claim lodged on 13 September 2004.
3. In a decision dated 10 June 2005, the Repatriation Commission accepted Mr McDonell’s claim for solar keratosis of both legs, bilateral tinnitus, sensorineural hearing loss of the left ear and pleural plaque and granted a disability pension at 10% of the general rate with the date of effect being 13 April 2004.
4. The Repatriation Commission rejected Mr McDonell’s claim in respect of xeroderma (constitutional), refractive error, irritable bowel syndrome, asthma, post traumatic stress disorder (‘PTSD’), alcohol dependence, depressive disorder and stasis dermatitis.
5. This decision was reviewed in part by the Veterans’ Review Board (‘VRB’) on 9 December 2005, with the decision of the Repatriation Commission being affirmed in relation to all matters apart from stasis dermatitis, which was accepted and depressive disorder and irritable bowel disorder, consideration of which was adjourned pending further investigation.
6. The adjourned decision of the VRB was further considered by the VRB on 11 July 2006 which further varied the original decision of the Repatriation Commission to include generalised anxiety disorder as an addition to the diagnosis of depressive disorder. The VRB also set aside the decision in relation to depressive disorder and concluded that such a disorder was war-caused with date of effect being 13 April 2004, with assessment remitted and payable from that date. The VRB affirmed the original decision in relation to irritable bowel syndrome.
7. At the commencement of the hearing, we were advised that the Applicant was not pursuing review in relation to the conditions of asthma, refractive error and diabetes. We were further advised by the Respondent that xeroderma (dry skin) was war-caused. We considered this concession and so find that xeroderma is war-caused with date of effect being 13 April 2004.
issues
8. The relevant issues in this matter are:
(a)What are the diagnosis(es) of the psychiatric conditions from which Mr McDonell currently suffers?
(b)Are the following conditions related to Mr McDonell’s service?
(i)depressive disorder
(ii)generalised anxiety disorder
(iii)alcohol dependence
(iv)irritable bowel syndrome
(c)Are the above injuries/diseases war-caused?
(d)Issue of remittal for assessment
summary of findings
9. For the reasons detailed later in this decision, we find that:
(a) the appropriate diagnoses for Mr McDonell’s current psychiatric conditions are –
(i) depressive disorder
(ii) generalised anxiety disorder
(iii) alcohol dependence
(b) the only psychiatric disease related to his service is depressive disorder
(c)depressive disorder is a war-caused disease with date of effect being 13 April 2004 and xeroderma is a war-caused disease with same date of effect
(d)the matter is remitted for assessment in relation to the two nominated war-caused diseases
considerations and findings – medical issues:
10. In a letter of referral to Dr Graham Altman (consultant psychiatrist) dated 30 September 2004 (Exhibit R2), Dr Ross Bills, the treating general practitioner, described Mr McDonell’s symptoms and associated clinical history in the following terms:
He describes ongoing stress and nerves, classically irritability and crankiness, poor sleep, circular thoughts, vivid dreams of being chased. No clear history of flashback or similar. He was near the machinery space on Queenborough when a boiler explosion killed a friend, with whom he had joined. He was also involved in the Melbourne/Evans collision, Vampire was involved in the rescue, and also served in SVN, Vung Tau harbour, with depth charging (scare charges) against enemy divers.
11. In a report dated 9 December 2004 (T11), Dr Altman details the circumstances of three events experienced by Mr McDonell including Mr McDonell’s response, namely:
(a)a trip to Vietnam in May 1969, on HMAS Vampire, with the latter acting as an escort to HMAS Sydney. Dr Altman records Mr McDonell as stating:
I was in the machinery spaces in the boiler room – the scare charges – I was at action stations. Pretty frightened. You could see the aircraft making bombing runs when we were at Vung Tau harbour.
(b)the HMAS Melbourne/USS Evans collision in June 1969. Dr Altman records Mr McDonell as stating:
I was on the HMAS Vampire in 1969. We got woken and were told the Melbourne had hit the Evans. We arrived there at about dawn. You could see the aft section of the Evans and there was just stuff everywhere in the water. We saw people’s belongings floating by. It is something you will never forget to see a ship cut in half – it was eerie – the time of the day. It was terrible. I woke up at night for a long time thinking about it. I never then wanted to go on to the Melbourne and then a few years later I got posted there – I was tense about it. It was not good.
In addition, he stated that when he saw the Evans “it was terrible. It was horrendous”.
(c)a trip to Vietnam on HMAS Sydney in November 1972. Dr Altman, in recording Mr McDonell as stating that the trip was stressful for him, detailed the following:
Actually just going into a war zone. I was below the waterline in the machinery spaces by the engines and by the refrigeration. There were scare charges going off all the time to keep anyone from attacking the Sydney. You were not allowed to show that you were frightened. My heart was racing – I was just nervous.
12. Dr Altman noted that Mr McDonell described his current symptoms in the following terms:
“I am not as happy”.
“I get irritable”.
“Cranky all the time”.
“I get stressed and I flare into anger for no reason”.
“I feel like I am on the verge of tears all the time”.
“I drink more than I should – I binge drink”.
“I get depressed and contemplate suicide”.
“I cannot settle down in jobs”.
13. Dr Altman also noted that Mr McDonell stated that prior to going to Vietnam, “I was a fairly easy going person – I did not drink much. Calm – fairly even-tempered”.
14. Dr Altman elicited the following responses from Mr McDonell as a consequence of direct questioning:
(a)suffers from nightmares twice a week since the late 1970s, with the content of the nightmares being detailed as, “I am being chased – I wake up frightened – lately there is one where I am shooting or something is being shot”.
(b)experiences recurrent intrusive distressing thoughts about his war experiences approximately twice a week.
(c)avoids the thoughts associated with his war experiences, and avoids talking about them, as well as generally avoiding Anzac marches and reunions.
(d)becomes distressed on exposure to some reminders of his war experiences.
(e)he is more of a loner.
(f)he feels detached from others.
(g)he has difficulty showing affection towards his daughters.
(h)suffers from sleep disturbance, with his sleep being restless and wakeful.
(i)poor concentration.
(j)far more irritable.
(k)has an exaggerated startle reaction.
(l)hypervigilant – “always I like to watch the doors”.
15. Dr Altman considered that the abovementioned features are indicative of a severe chronic PTSD.
16. Dr Altman also considered that Mr McDonell presented with a number of significant depressive symptoms indicative of a major depression. Such symptoms included low mood, sleep disturbance, diurnal variation in mood, diminished energy, low libido, impaired concentration, low confidence and motivation, a loss of enjoyment with most activities to a large extent, making big issues out of relatively minor issues and no current suicidal thoughts.
17. Dr Altman noted Mr McDonell as getting drunk on a two weekly basis during which he will drink twelve beers, two bottles of wine and on occasions much more. Aside from the two weekly episode, Dr Altman records Mr McDonell as drinking four standard drinks per day. Dr Altman also records Mr McDonell as drinking socially prior to going to Vietnam, and thereafter while in the navy drinking alcohol excessively when ashore. Dr Altman concluded that Mr McDonell was also suffering from alcohol dependence.
18. Dr Altman detailed Mr McDonell’s work history, with his departure from Blackwoods in 1999 (recorded as 1988) after 23 years, after which “it all just started to fall apart”. Dr Altman records that Mr McDonell was back working with Blackwoods in 2003, after a succession of jobs, in which he was unable to settle down and “it all got on top of me”. In his then, current job, Mr McDonell is recorded as stating he is “irritable, anger – I am snappy – intolerant”.
19. Dr Altman records Mr McDonell as stating that his childhood was not happy.
20. In a further report dated 21 November 2005 (T24/154), Dr Altman addressed further the issue of experiencing a stressor. In relation to the HMAS Sydney experience in 1972, there was a further definition of the event and Mr McDonell’s responses to the event. Dr Altman records Mr McDonell as stating:
I was locked alone in a small refrigeration space – we were at action stations. I was below the waterline. Without warning I heard a number of close loud explosives. I thought we had been attacked. They were loud and very frightening. I tried to get out of the space, but was told to get back down there. I thought I would be killed. I was so frightened for my life – I pissed my pants. I thought I was going to die and you are not allowed to show you are frightened.
21. In relation to the May 1969 event, Dr Altman records Mr McDonell as stating:
In May 1969 I was serving on HMAS Vampire. We were on high alert in Vietnamese waters going to Vung Tau harbour. As we entered Vung Tau harbour I saw that there was aircraft bombing and straffing on the shore land. I was very scared. I then had to go on watch in the boiler room though the airlock – the boiler room is below the waterline. Without warning there were a number of explosions. The ship shuddered and lagging fell from above. I thought we were being attacked. I was scared I was going to die – I felt trapped. I thought I was going to die – I though I was going to drown. From then on I would not go below the waterline unless I was on watch.
22. Dr Altman noted that Mr McDonell had ceased work with Blackwoods again in 2005, noting that Mr McDonell reported that “I cannot stand interacting with people. I get to the point where I am about to explode and at times I do explode. I am abusive and threaten physical harm to my co-workers and I just hang up on the clients”. Dr Altman noted that Mr McDonell reported that, “I get very tense and tight – extremely tense and tight. I get headaches. I have to get up from my desk and walk away because I am afraid I might lose my temper … I get headaches and heart palpitations. It is stupid anger”.
23. In a further report dated 27 June 2007 (Exhibit R11), Dr Altman confirmed his earlier diagnoses that Mr McDonell suffered from a severe chronic PTSD with an associated major depression and alcohol dependence, for which he was being treated with anti-depressant medication and lamictal for his anger and irritability.
24. In oral evidence, Dr Altman again confirmed his diagnoses, with an opinion that the PTSD had been caused by Mr McDonell’s Vietnamese experiences, and perhaps aggravated by the events of the Melbourne/Evans collision. In response to questions in cross examination, Dr Altman stated:
·that the incident involving the boiler explosion and the death of a sailor on HMAS Queenborough prior to Mr McDonell’s Vietnam experience in May 1969 was not deliberately hidden or withheld by Dr Altman, in that the Vietnam experiences were the ones foremost in Mr McDonell’s history of events;
·that the Queenborough incident did not appear to have caused the onset of his nightmares and his PTSD symptoms;
·that the Queenborough incident did not come out initially, but only at a later stage, and despite it being in the letter of referral, it was an oversight not to have addressed the issue until later;
·that he was aware that Mr McDonell had been sexually accosted by another sailor on HMAS Queenborough, with Mr McDonell being reported by Dr Altman as not finding this incident traumatic;
·that any incident involving contraction of venereal disease is a peripheral issue in considering the current problems;
·that seeing a friend in a body bag is necessarily more stressful than thinking he’s going to die himself is very debatable;
·the incident on the HMAS Melbourne where the catapult used for launching aircraft did not function properly, with the aircraft ending in the sea was potentially a traumatic episode for Mr McDonell as he was a member of the catapult party – Dr Altman being unable to recall as to whether or not he was aware of this event. In a later response, Dr Altman believed that Mr McDonell would have had to witness the event for it to be considered a traumatic event;
·that with psychiatric patients, it is often difficult to get a complete history;
·that the value of conclusions reached is largely dependent on the thoroughness of the history taken, which includes collateral information gained from others, such as in this matter, his wife;
·that he has found Mr McDonell to be an honest person, and that he takes a while before he will open up. In such circumstances, he could understand why other clinicians may consider him a poor historian;
·that psychological testing requires careful interpretation and assessment in the light of the clinical situation;
·that he was unable to recall whether he was aware that Mr McDonell had left Blackwoods on the first occasion in 1999 for personal reasons (did not want to leave Canberra);
·that he was aware that Mr McDonell had suffered some anxiety as a consequence of an x-ray finding of pleural plaques, but was unaware that Mr McDonell had made a claim for a depressive disorder as a consequence of such a finding;
·that Mr McDonell has suffered from alcohol dependence since 1971/72, but disagrees with Professor Mattick, a consultant psychologist, when Professor Mattick concludes that he “doubts that he met criteria for PTSD and points out that he worked well for many years after service”;
·that to postulate that Mr McDonell’s condition came on in around 2000 “is just to me absolutely quite unbelievable”;
·the diagnosis of PTSD was made in the absence of the knowledge of the Queenborough incident, with Dr Altman becoming focussed on the latter incident in July 2007.
Dr Koller – Consultant Psychiatrist
25. In a brief report dated 11 August 2005 (T22/104), Dr Karl Koller, a consultant psychiatrist, concluded that Mr McDonell was suffering from PTSD and alcohol dependence. Dr Koller refers to the boiler incident on HMAS Queenborough in 1967/68, the trips to Vung Tau harbour in May 1969 and November 1972, and the Melbourne/Evans collision in June 1969, as cumulative horrors and traumas that have allowed PTSD to evolve.
Dr Dinnen – Consultant Psychiatrist
26. In a report dated 21 August 2006 (Exhibit A2), Dr Anthony Dinnen detailed Mr McDonell presenting the following scenario:
It appears matters came to a head about ten years ago. He said that at the time his wife was causing him to feel annoyed, travelling on public transport was becoming a problem and he didn’t like crowds or being with people. ‘I was becoming such a burden I thought I could finish it, drive the car into a tree on the way to work so someone wouldn’t find me’. He was planning to do that in Canberra near the Cotter Dam, on the road known as the ‘Cotter Loop’.
His wife kept saying to him at the time that he had to get some help. ‘I kept saying it was her’. He didn’t tell her when he first felt suicidal.
27. Dr Dinnen noted Mr McDonell’s current symptoms to include:
He is impatient. He feels irritable and angry, but not as bad as he was. Stays inside most of the time. Has stopped drinking, while previously drinking three to four cans of beer a day plus wine while at weekends a dozen cans and two bottles of red wine. He continues to suffer from depression with good and bad days, but better than it was.
28. In relation to his service history, Dr Dinnen notes that Mr McDonell was twice in Vietnam on HMAS Vampire in May 1969 and HMAS Sydney in 1972. Dr Dinnen reports that Mr McDonell was in the machinery space when they were dropping scare charges, and that he had nightmare for months afterwards and started drinking. Dr Dinnen also records the events of the Melbourne/Evans collision in June 1969, and notes that after Mr McDonell returned to Vietnam in 1972 on HMAS Sydney, he was drinking and aggressive and had nightmares at the time. The nightmares were described as people chasing him, with blood on the wall, and he would attack his wife in bed, as well as being very unsociable and fairly withdrawn. Dr Dinnen noted that the service documents reported Mr McDonell seeking assistance for tension headaches while serving on HMAS Sydney in 1973. Dr Dinnen also noted the history of the boiler incident and the sexual assault while Mr McDonell was serving on HMAS Queenborough. Dr Dinnen also recorded a history of an unhappy and troubled childhood, with a disciplinarian stepfather, and much strife and involvement in undetected petty crime. Dr Dinnen records Mr McDonell as having married in 1972, having met his wife some two years earlier and that there were two children from the marriage, namely a daughter who lives in London and a son who lives in Canberra.
29. Dr Dinnen in summary opinion observed that Mr McDonell presented a range of symptoms of anxiety and depression and alcohol abuse. Dr Dinnen did not see good evidence for the diagnosis of PTSD but considered that Mr McDonell did suffer from anxiety disorder associated with alcohol abuse following his service in the navy and exposure to various stressful events. Dr Dinnen also considered that the condition significantly worsened after the discovery of pleural plaques. Dr Dinnen did not consider Mr McDonell a good historian.
30. In a further report dated 17 October 2006 (Exhibit A3), Dr Dinnen noted the history of Mr McDonell’s alcohol consumption as described in Professor Richard Mattick’s report of 26 July 2006. Dr Dinnen noted that Mr McDonell’s clear account is that his heavy drinking commenced in response to stressful experiences during service, that he first noticed that he could become shaky if he had not drunk alcohol when he was stationed at HMAS Nirimba in 1970 (approx). Dr Dinnen also notes that recurrent alcohol abuse has led to a failure to fulfil major role obligations both in the navy and in his employment at Blackwoods. Dr Dinnen observed that Mr McDonell was recorded as stating that he continued to drink in circumstances which were physically hazardous, as well as reported fights when he was drinking and many arguments with his wife about his drinking. Dr Dinnen was generally in agreement with Professor Mattick’s opinion in so far as it mirrored his own.
31. Dr Dinnen also examined Dr Robert Lewin’s reports of July and September 2006. He noted that Dr Lewin considered that Mr McDonell had trait anxiety present during his childhood causing him to be vulnerable to stressful experience. He noted that Dr Lewin considered it likely that Mr McDonell had an anxiety disorder prior to joining the navy. He observed that Dr Lewin considered that Mr McDonell was suffering from major depression and alcohol dependence in partial remission. Dr Dinnen noted that Dr Lewin did not consider that the pattern of drinking explained the persisting symptoms, thereby confining his diagnosis to recent years, with the symptoms of anxiety and depression arising in response to gradually losing control of his work environment, with such an immediate explanation far more likely than a distant explanation involving events in the navy many years earlier.
32. Dr Dinnen concluded that Dr Lewin is very much at odds with the opinions of himself, Dr Altman and Dr William Knox, in the circumstances where Dr Lewin concludes that Mr McDonell’s psychiatric condition is of recent onset, and also in the circumstances where he concludes that the anxiety experienced following the diagnosis of the chest condition was not clinically significant.
33. In oral evidence Dr Dinnen considered that Mr McDonell was open and frank about the experiences he was complaining of, and that if anything he was inclined to diminish the information that he was giving rather than embellish or exaggerate. Dr Dinnen considered that the clinical onset of Mr McDonell’s depressive symptoms was about ten years ago (1995/1996), with this being superimposed on an emotional disturbance developed during service as a consequence of various experiences, which led to symptoms of nightmares and tension, aggression and particularly heavy drinking. Dr Dinnen assumed that there were problems with mood associated with the onset of the anxiety problem together with a drinking problem from his earlier years in the navy. Dr Dinnen considered that the three conditions present, namely the depressive disorder, the anxiety disorder and the alcohol abuse, were intertwined, with varying symptomatology over time.
34. Dr Dinnen observed that it was his training and his belief that there has to be some underlying psychiatric problem for an addiction, abuse or dependence to develop, but quite often that is not evident (i.e. the clearly defined psychiatric disorder). Dr Dinnen considered in this matter that apart from the level of emotional disturbance, such was the case, with the emotional disturbance characterised by the three features of anxiety, depression and alcohol abuse, providing support for a belief of an underlying psychiatric problem.
35. Dr Dinnen considered that the event most associated in Mr McDonell’s mind with the development of psychological distress was the May 1969 incident in Vung Tau harbour, with this leading to him being aware of psychological disturbance characterised by nightmares and drinking. Dr Dinnen observed that Mr McDonell did not develop any psychological symptoms from the boiler incident on Queenborough in 1967/68, although it would have predisposed him to a level of apprehension by the time he went to Vietnam in May 1969. Similarly Dr Dinnen noted that Mr McDonell had no emotional reaction to either the Melbourne/Evans incident in June 1969, or indeed the further visit to Vietnam in 1972 on HMAS Sydney which caused no particular reaction. Dr Dinnen concluded that Mr McDonell was a man who is given more to describe a situation rather than to allocate psychological or emotional responses to it.
36. In response to questions in cross examination Dr Dinnen stated that the issue of clinical onset is a very complex matter and in this matter he believed Mr McDonell was aware of the seriousness of his condition, when he was thinking of doing away with himself. Dr Dinnen believed both the onset and clinical onset of the condition occurred during his service years, with the condition commencing to deteriorate about 10 years ago, which was at the time he first received medical attention for his condition. Dr Dinnen also observed that because Mr McDonell was successful in a job over a long period, this, alone does not exclude the presence of underlying difficulties, with an acknowledgment that many people cope with their psychiatric problem by maintaining activity in employment.
37. In further response Dr Dinnen did not think that Mr McDonell was a loner, which he believed was a personality characteristic – which he distinguished from one who is not very sociable and somewhat withdrawn, and in Mr McDonell’s case there did not seem to be any strong evidence of difficulty forming relationships during his formative school years. Dr Dinnen noted that Mr McDonell had told him that during his early years in the navy he had become aggressive and that may have interfered with formed relationships, but not necessarily with an ability to form relationships.
38. Dr Dinnen also considered that looking at a bunch of soldiers, described as scary suggests to him that they were traumatised people, which in turn suggests to him that they may have had an emotional impact on Mr McDonell (HMAS Sydney in Vung Tau, 1972). Dr Dinnen considers that in such circumstances, such an event may constitute a severe stressor or a psychological stressor.
39. Dr Dinnen, when questioned, stated that the catapult incident on HMAS Melbourne was a significant incident although he had not been told of it, and would have had an effect on Mr McDonell. Dr Dinnen expressed his opinion that he was not surprised that he was not told, as it was consistent with Mr McDonell’s reluctance to talk about anything very much.
40. Dr Dinnen also expressed the opinion that the Queenborough incident in 1967/68 was likely to have a marked impact on Mr McDonell, although he had no information that the event led to any psychological disturbance at that time. Dr Dinnen believed the Queenborough incident was a traumatic incident, but essentially a stressor that has to be considered with other stressors experienced during his service. In the absence of evidence of psychological disturbance after the incident on the Queenborough, Dr Dinnen considered that at least it would have made Mr McDonell more vulnerable to later stressors, as evidenced by him developing problems in May 1969 after his trip to Vietnam.
41. Dr Dinnen also agreed that the sexual accosting by another sailor on HMAS Queenborough would have been a traumatic event, causing Mr McDonell to be both vulnerable and apprehensive.
42. Dr Dinnen considered that there was no evidence that Mr McDonell had an anxiety disorder before he joined the navy, and that he had no evidence of an anxiety disorder until after the Vietnam period of service in May 1969.
43. Dr Dinnen also expressed an opinion that infection with a sexually transmitted disease at a younger age would be traumatic and have an impact on a person’s well being for some time and maybe indefinitely. Dr Dinnen agreed with the proposition that there were a combination of events which impacted on Mr McDonell’s emotional adjustment at that time.
44. Dr Dinnen confirmed his opinion that the appropriate diagnostic label in this matter was generalised anxiety disorder, with mixed anxiety and depressive symptomatology of varying severity since 1971, intertwined with alcohol abuse/dependence, with the depressive element aggravated over the last ten years. Dr Dinnen observed that he may have had a personality trait in which his whole coping style is more one of trying to beat back his emotions, coupled with the use of alcohol, to a point in time when his defences fail.
45. Dr Dinnen was specific in acknowledging that there was not a set of clinical symptoms defined or definable at the time of Mr McDonell’s service which would justify a diagnosis now of anxiety disorder except by arguing that he started drinking, these things have happened and he had nightmares, indicative of disturbance and an assumption that there was an underlying anxiety disorder. Dr Dinnen considered that the only time one can make a diagnosis of a psychiatric condition, is when he presented for medical attention back three or four years.
Dr Lewin – Consultant Psychiatrist
46. In a report dated 26 July 2006 (Exhibit R5), Dr Lewin detailed Mr McDonell’s work history post service, his service history in which he notes Mr McDonell as reporting a good record in the navy with nine years of undetected crime, after joining the navy as a young, naïve, sensitive and, perhaps “a bit of a loner” type person. Dr Lewin noted that Mr McDonell wanted to be a cook; that he felt apprehensive whilst working below the waterline in a confined space; that he felt fearful about such activities from the earliest stages of his service and that he did not want to let older men know that he was afraid. Dr Lewin noted that Mr McDonell did not like the experience of mess deck life. Dr Lewin noted Mr McDonell’s reaction to scare charges in Vung Tau harbour as one of fearing that something terrible might happen and a desire to escape through a hatch, which he did not do. Dr Lewin reports Mr McDonell felt fearful at the outset, thinking the water would come through the plates and he felt he might die. Mr McDonell is reported as stating his nerves settled after leaving Vung Tau harbour and that he did not report any symptoms in the months which followed. Dr Lewin also records aspects of the Melbourne/Evans collision.
47. In addressing Mr McDonell’s psychiatric history, Dr Lewin observed that the impact of temper, irritability, retreating into himself and increased drinking were symptoms noted by Mrs McDonell and drawn to her husband’s attention some five years earlier. Mr McDonell is also reported as stating bad dreams became an issue at that time. Mr McDonell is reported as stating that he was not a nice person to be around and that he had alienated friends both in a social setting and in the workforce. Mr McDonell reported a poor pattern of sleep, with no initial insomnia, but waking during the night, often feeling frightened and in an agitated state. Mr McDonell reported that he often feels low and dispirited, his energy level is sometimes terrible, but prior to taking particular medication his libido was alright. Mr McDonell reported that he used to be intensely irritable, feared aggressive outbursts, and was emotionally labile, all of which had largely settled with treatment. Mr McDonell reported ruminating about suicide several years ago and when asked to leave work in 2003. Dr Lewin notes that Mr McDonell was very distressed at losing his job after 20 years as a senior manager, and similarly when he recognised that he was unable to manage in a less senior position and that he felt less worthy. Dr Lewin detailed a history of Mr McDonell’s alcohol usage and concluded that Mr McDonell suffered alcohol dependence in partial remission.
48. Dr Lewin noted a pattern of symptoms in Mr McDonell’s background history which he believed to be consistent with trait anxiety.
49. In summary opinion Dr Lewin considered that Mr McDonell has a partially treated depressive reaction, with the frequency and intensity of symptoms diminishing in response to treatment. Dr Lewin noted that Mr McDonell had no record of any sustained pattern of symptoms prior to his presentation in 1999. Dr Lewin concluded that Mr McDonell has major depression in partial remission and alcohol dependence in partial remission. Dr Lewin considers that the date of the clinical onset of the psychiatric condition was in 2001. Dr Lewin believed that Mr McDonell demonstrated a pattern of behaviour in his formative years which he described as trait anxiety. Dr Lewin believed that Mr McDonell had a degree of genetic vulnerability for anxiety which in generic terms in all probability amounted to an anxiety disorder predating his period of navy service.
50. Dr Lewin considered the three traumatic events nominated as having been experienced by Mr McDonell. Dr Lewin noted that while there were temporary symptoms of worry and fear, there was no enduring symptoms or impairment of function, nor was there any report of Mr McDonell seeking treatment. Further Dr Lewin concluded that Mr McDonell’s pattern of drinking does not explain the persistent symptoms. Dr Lewin considered that the origins of Mr McDonell’s psychiatric condition were more to do with the circumstances of him leaving Blackwoods in 1999.
51. Following further consideration, Dr Lewin in a report dated 12 September 2006 (Exhibit R6), affirmed the opinion he had expressed earlier.
Dr Knox – Consultant Psychiatrist
52. In a report dated 9 March 2006 (T24/173), Dr Knox noted that Mr McDonell reported himself as a loner, still binge drinks, is intolerant of people and frequently cranky, and having considerable concern about the pleural plaques discovered in 2005. Dr Knox considered that Mr McDonell’s depressive condition did not begin or significantly worsen with the discovery of the plaques.
53. Dr Knox records that Mr McDonell dates the onset of his depression in the early 1970s, with it having worsened in recent years, especially since leaving Blackwoods on the first occasion.
54. Dr Knox noted that Mr McDonell found his early experiences in the navy challenging, as he was a sensitive young man and “not one of the boys, not a matey type”. Dr Knox ascribes Mr McDonell as beginning to drink excessive amounts of alcohol early in his navy career to “forget, escape”. Dr Knox also noted that Mr McDonell ascribed his exposure to war service in May 1969 as a significant element in causing and/or aggravating his developing depressive disorder, which Dr Knox believes is best described as dysthymic disorder. Dr Knox noted that Mr McDonell spent further time in Vietnam in 1972, but with less fear.
55. Dr Knox believes the Melbourne/Evans collision in 1969 (recorded as 1972) played a part in reinforcing the dysthymic disorder and the PTSD.
56. In addressing the diagnostic criteria for dysthymic disorder, Dr Knox observed that Mr McDonell has poor concentration, a sense of hopelessness, significant fatigue, a strong sense of worthlessness, sleep disturbance and a pervasive unhappiness of mood likely present over the greater part of his adult life. Such symptoms were associated with his navy service, as well as reflecting traits in his personality. Dr Knox also noted Mr McDonell’s heavy and regular use of alcohol, and further his symptoms of lethargy, impatience, irritability, nightmares, poor sleep, guilt, indecisiveness and low mood.
57. Dr Knox stated that he did not explore the diagnosis of PTSD. Dr Knox also concluded that Mr McDonell satisfied the diagnostic criteria for generalised anxiety disorder throughout much of his adult life, with Mr McDonell’s certain anxious traits in his adolescence setting the scene for his dysthymic disorder and generalised anxiety disorder.
Professor Mattick – Consultant Psychologist
58. In a report dated 26 July 2006 (Exhibit R8), Professor Mattick detailed Mr McDonell’s childhood, work and service history. Professor Mattick noted Mr McDonell’s response to the Queenborough incident as, “I was a bit shocked … at the time you don’t think much of it … it’s later on these things come back to you … especially as I did not want to be a stoker … I wanted to be a cook”. Further Professor Mattick reports that Mr McDonell could not identify any specific reaction to the event, nor any other event occurring on the Queenborough that caused him any distress.
59. Professor Mattick records Mr McDonell as stating that in relation to the scare charges on his first trip to Vietnam in May 1969 that “… it bloody scared the hell out of me and I didn’t sleep for days afterwards”. In relation to the Melbourne/Evans collision Professor Mattick noted Mr McDonell’s reaction as “shocked … I did not know how to react … you were not allowed to show it … guys were supposed to be macho … but it just made me more frightened”. Professor Mattick then records Mr McDonell as stating, when the ship returned to Singapore after the two incidents “I got absolutely rolling, stinking drunk on beer and spirits … I’d not been much of a drinker before that”.
60. Professor Mattick records that Mr McDonell drank heavily while at HMAS Nirimba, and that when returning to Vung Tau harbour in 1972 on HMAS Sydney, the explosion of scare charges “brought it all back to me … I felt frightened … I wet my pants as I didn’t get relieved to go to the toilet”. Professor Mattick detailed that the catapult incident on HMAS Melbourne was reported by Mr McDonell as having no effect on him.
61. Professor Mattick detailed Mr McDonell’s lifetime’s history of alcohol consumption and that in relation to alcohol abuse after consideration of such history, he considered that the clinical onset of alcohol abuse was in 1971 or 1972, noting that Mr McDonell:
·had, with recurrent substance use, failed to fulfil major role obligations at work, at home and when on HMAS Vampire;
·had, with recurrent substance use, done so in situations that would be physically hazardous;
·had not experienced any legal problems because of drinking;
·had been involved with many fights when drinking from 1971, 1972, 1973;
·had been aggressive, argumentative, nasty when drinking on return to port from 1970 onward.
62. In relation to alcohol dependence, Professor Mattick considered that Mr McDonell had some symptoms of alcohol dependence from 1970 (suffering shaking while at HMAS Nirimba), some tolerance and spending a great deal of time drinking from some time in the 1980s. Professor Mattick considered the clinical onset for alcohol dependence was some time in the 1980s.
63. Professor Mattick considered that Mr McDonell exaggerated his emotional disturbance on questionnaires. In his opinion, it was implausible that he suffers the level of emotional disturbance that he suggests he does on questionnaires in the light of his presentation during the consultation.
64. Professor Mattick did not believe that Mr McDonell met the criteria for the diagnosis of PTSD. Professor Mattick considered that Mr McDonell developed a depressive disorder, with onset in 2000, when the issue of the first severance from Blackwoods was evident. Further, Professor Mattick did not believe Mr McDonell’s condition had become clinically worse since diagnosis.
65. In oral evidence, Professor Mattick confirmed that at examination, he was unable to detect any symptoms of anxiety or depression. Further, Professor Mattick confirmed that as a consequence of answers given by Mr McDonell in the self reporting questionnaire given to him to complete, the results are consistent with a view that Mr McDonell is exaggerating emotional disturbance. Professor Mattick was specific in drawing a distinction between exaggerating responses to a questionnaire and feigning psychiatric illness.
issue of diagnosis
66. In addressing the issue of current diagnosis of Mr McDonell’s psychiatric disorder, we are much mindful of the history provided by him in his formal statement of 11 September 2006 (Exhibit A1), his evidence to the tribunal and the many histories recorded by treating and evaluating specialists. We have been particular in detailing the various specialist opinions in relation to Mr McDonell’s exposure to various incidents during service, his response to such exposures and his symptomatology as described by him and detailed in the many specialist reports.
67. In terms of Mr McDonell’s response to the various incidents experienced during service, we note the following from his oral evidence:
·the boiler room incident on HMAS Queenborough
-traumatised him
·on the trip to Vung Tau in May 1969
-“I didn’t want to be a stoker”
-“I didn’t want to be below the waterline”
-“That scared me – I was terrified to be honest”
·in Vung Tau harbour in May 1969
-some knowledge of Operation Awkward
-was in the boiler room when charges were detonated
-“I was terrified, I didn’t know what it was. I thought I was going to die. I thought we were being attacked … I thought I was going to drown … I thought I was dead”
· after leaving Vung Tau in May 1969
-“I was a basket case”
-“I couldn’t think properly”
-“I was nervous”
-“I got mind traffic” (full of thoughts)
-“I was scared, anxious and not wanting to go down into machinery spaces”
-“slept on deck after what happened to his friend” (Queenborough incident)
-In Singapore – got drunk – issue with Red Caps
· the Melbourne/Evans collision June 1969
-“very uncomfortable”
-“I was already tense”
-“I was already apprehensive”
-“I was very anxious”
· HMAS Nirimba 1970-1971
-drank a dozen middies every night
-withdrawn
-depressed (when he went home he wanted to listen to music and not communicate)
-nightmares (water rushing in, blood on walls)
-mind traffic (used to haunt him)
· HMAS Brisbane 1971 (On announcement ship was going to Vietnam)
-terrified, scared
-I didn’t want to go
-I didn’t know how I was going to cope
· HMAS Sydney 1972
-frightened about going to Vietnam
-thoughts about being below the waterline, in a small machinery space with hatches closed down
-in Vung Tau harbour, felt frightened and anxious
-frightened and guilty on meeting a group of scary, tense soldiers
We also note that Mr McDonell has repeated often that he wanted to be a cook and not a stoker and that he attempted to change branches. Further it is noted that Mr McDonell stated that he was scared of confined spaces and especially below the waterline prior to the Vampire posting. Also, we note that Mr McDonell found it difficult to sleep in the mess for a number of reasons including heat, cramped conditions, personal preference, and that is why he preferred to sleep on the upper deck.
68. We note that Dr Dinnen considered that Mr McDonell was not a good historian. In so stating, Dr Dinnen acknowledged that Mr McDonell was open and frank about his experiences; that he was inclined to diminish the information he was giving rather than embellish or exaggerate. Dr Dinnen concluded that Mr McDonell was a man who is given more to describe a situation rather than to allocate psychological or emotional responses to it. We note that Professor Mattick considered the responses given by Mr McDonell when completing the self reporting questionnaires would suggest that Mr McDonell was exaggerating emotional disturbance. We note an increase in the nature of the response nominated over time as detailed by Mr McDonell in relation to the May 1969 and November 1972 response to being in the machinery space when scare charges were detonated, which in our view appeared to be constructed to deal with the issue that the stressors might not be considered to be severe enough to warrant a diagnosis of PTSD.
69. Nevertheless in spite of the issues outlined, we consider that Mr McDonell has detailed his clinical history as best he could, and that variability in the history taken by the various consultants reflects the well being of Mr McDonell at the time, the inherent communication skill of Mr McDonell, the length of time available for the consultation and the particular methodology of the assessing specialist.
70. In addressing the issue of diagnosis, we are mindful that such a finding must be made on grounds of reasonable satisfaction. In such circumstances we conclude that Mr McDonell’s current diagnoses are:
(a)depressive disorder;
(b)generalised anxiety disorder; and
(c)alcohol dependence.
71. In so finding, we are mindful of Mr McDonell’s current symptomatology and the opinions expressed by the various specialists detailed earlier in this decision. We observe that Mr McDonell has been treated since 2004 by Dr Altman and has received medication for both depressive and anxiety symptomatology, and that he continues to receive such treatment.
72. We acknowledge that Drs Altman, Lewin and Knox all consider Mr McDonell to have a depressive disorder either by way of a depressive episode or a dysthymic disorder (Dr Knox), while Professor Mattick considered Mr McDonell to have developed a depressive disorder around 2000. Dr Dinnen considered that Mr McDonell has a generalised anxiety disorder with mixed anxiety and depressive symptomatology. Dr Knox also confirms a diagnosis of generalised anxiety disorder.
73. Dr Altman and Dr Koller consider that the appropriate diagnosis in this matter is PTSD with major depression (Dr Altman) and alcohol dependence. We do not accept the diagnosis of PTSD as a valid diagnosis in this matter for the following reasons:
(a)While we note that there has been a range of incidents experienced by Mr McDonell during his service, we observe that the incidents on the Queenborough and the Melbourne/Evans collision, while they did occur, do not fall within the scope of the Veterans’ Entitlements Act 1986 (‘VE Act’) as such incidents did not fall either within a period of operational service or defence service.
(b)Nevertheless such incidents need to be considered in understanding the service origins, if any, of Mr McDonell’s current psychiatric disorders. In this regard both the Queenborough incident and the Melbourne/Evans collision aftermath could be considered to be events in which Mr McDonell experienced, witnessed or was confronted with events that involved actual or threatened death or serious injury (Woodward v Repatriation Commission (2003) 131 FCR 473, considered and followed). It is our opinion that the same could be said for the initial scare charge incident in May 1969, albeit with some reservations (awareness generally of the defensive operations), but not for the second scare charge episode in November 1972 because of his previous experiences.
(c)Irrespective of our finding in relation to the nature of the incidents, we have been particular in detailing Mr McDonell’s response to each of these incidents earlier in our decision. While we note Dr Dinnen’s observations that Mr McDonell was better able to describe an incident/event than enunciate his emotional response to such, we conclude that none of the responses detailed by him in the context of a particular incident/event involved intense fear, helplessness or horror.
(d)We observe that Dr Knox did not seek to address the diagnosis label of PTSD, accepting that it had been a diagnosis made by other psychiatrists. We consider Dr Koller’s opinion of minimal assistance in that the opinion is devoid of supportive clinical reasoning and analysis. We are mindful that Dr Altman’s opinion was formed after his first consultation in 2004. We observe that such a diagnosis was made in the absence of any consideration of the two events on the Queenborough (boiler explosion and sexual assault) and the catapult episode on HMAS Melbourne. We do note, however, that such a diagnosis was maintained by Dr Altman after consideration of such events, on the premise that the most pertinent and relevant events were the two operational service incidents in Vung Tau harbour in May 1969 and November 1972.
(e)Further, we bear in mind the opinions of Drs Dinnen and Lewin and Professor Mattick. We note that each concluded that the symptomatology complained of by Mr McDonell was not sufficient to meet the criteria necessary for a diagnosis of PTSD. We prefer their opinions, particularly when the opinions of Dr Dinnen and Professor Mattick were tested in cross examination, while the opinion of Dr Altman was tested in circumstances where the difficulties with his opinion had been much in evidence.
For these reasons, we consider the opinions of Drs Dinnen and Lewin and Professor Mattick had been formed, as a consequence of a detailed and careful exploration of a more complete clinical history and objective evaluation thereof. While we also heard oral evidence from Dr Altman, we remained unconvinced by his analysis which seemed to ignore the Queenborough incident as regards the death of a fellow enlistee, despite such being drawn to his attention in the letter of referral from Dr Bills.
74. In finding that Mr McDonell does not on the balance of probabilities satisfy the criteria for a diagnosis of PTSD, we, as earlier indicated, rely upon the opinions of Drs Dinnen and Lewin and Professor Mattick. In addition, as already concluded earlier we are satisfied that Mr McDonell’s current psychological condition is best described as both a depressive disorder and a generalised anxiety disorder.
75. Further, in concluding that Mr McDonell also satisfies the criteria for a diagnosis of alcohol dependence (in remission), we observe that this is a consistent opinion of all the specialist opinion in this matter.
relationship to service
76. In addressing the condition of depressive disorder, we observe that there is material pointing to Mr McDonell experiencing particular events during service, with the contention that as a result of such experiences, he developed symptoms consistent with a dysthymic disorder and/or a depressive disorder. We observe that such a hypothesis is concerned with Mr McDonell’s experiences while on operational service in May 1969 and November 1972.
77. We note that the relevant Statement of Principles (SoPs) is Instrument No. 27 of 2008 concerning depressive disorder. We note that within this SoP, depressive disorder is defined to encompass both dysthymia and major depressive disorder.
78. We have earlier stated that there is material pointing to symptomatology congruent with the necessary formulations for a diagnosis of depressive disorder.
79. In addressing the issue as to whether such a hypothesis is reasonable, we acknowledge the following factors, nominated within paragraph 6 of the SoP, which are considered relevant, and for the hypothesis to be considered as reasonable, one of these factors must exist. For a factor to exist there must be material pointing to each element in the factor. Paragraph 6 of Instrument No. 27 of 2008 provides:
6 (a) (ii) experiencing a category 1A stressor within the five years before the clinical onset of depressive disorder;
(iii) experiencing a category 1B stressor within the five years before the clinical onset of depressive disorder;
(vi) experiencing a category 2 stressor within the one year before the clinical onset of depressive disorder;
(vii) having a clinically significant psychiatric condition within the two years before the clinical onset of depressive disorder; ……
80. We note that paragraph 9 of Instrument No. 27 of 2008 defines the following terms:
"a category 1A stressor" means one or more of the following severe traumatic events:
(a) experiencing a life-threatening event;
(b) being subject to a serious physical attack or assault including rape and sexual molestation; or
(c) being threatened with a weapon, being held captive, being kidnapped, or being tortured;
"a category 1B stressor" means one of the following severe traumatic events:
(a) being an eyewitness to a person being killed or critically injured;
(b) viewing corpses or critically injured casualties as an eyewitness;
(c) being an eyewitness to atrocities inflicted on another person or persons;
(d) killing or maiming a person; or
(e) being an eyewitness to or participating in, the clearance of critically injured casualties;
"a category 2 stressor" means one or more of the following negative life events, the effects of which are chronic in nature and cause the person to feel on-going distress, concern or worry:
(a) being socially isolated and unable to maintain friendships or family relationships, due to physical location, language barriers, disability, or medical or psychiatric illness;
(b) experiencing a problem with a long-term relationship including: the break-up of a close personal relationship, the need for marital or relationship counselling, marital separation, or divorce;
(c) having concerns in the work or school environment including: on-going disharmony with fellow work or school colleagues, perceived lack of social support within the work or school environment, perceived lack of control over tasks performed and stressful work loads, or experiencing bullying in the workplace or school environment;
(d) experiencing serious legal issues including: being detained or held in custody, on-going involvement with the police concerning violations of the law, or court appearances associated with personal legal problems;
(e) having severe financial hardship including: loss of employment, long periods of unemployment, foreclosure on a property, or bankruptcy;
(f) having a family member or significant other experience a major deterioration in their health; or
(g) being a full-time caregiver to a family member or significant other with a severe physical, mental or developmental disability;
"a clinically significant psychiatric condition" means any Axis I disorder of mental health that attracts a diagnosis under DSM-IV-TR which is sufficient to warrant ongoing management, which may involve regular visits (for example, at least monthly), to a psychiatrist, clinical psychologist or general practitioner; ……
81. In his analysis, Dr Lewin points to Mr McDonell suffering from anxiety traits during childhood being consistent with a constitutional origin. Dr Dinnen also points to such anxiety traits in Mr McDonell’s personality, but considers such acquired as a consequence of a troubled childhood and adolescence. We acknowledge that there is much material pointing to Mr McDonell being apprehensive and a worrier prior to service as well as in his initial years of service and during his periods of operational service. There is clearly no material before us which would point to Mr McDonell having a clinically significant psychiatric condition in terms of the definition nominated, either prior to service or during his service. In our view the material points to Mr McDonell satisfying such a definition, with the clinical onset of the condition occurring in 1999, as evidenced by the opinions of Drs Dinnen and Lewin and Professor Mattick.
82. We observe that there is material pointing to Mr McDonell experiencing either a category 1A and/or 1B stressor in relation to various experiences on HMAS Queenborough (death from the boiler explosion, sexual assault) and the Melbourne/Evans collision when serving on HMAS Vampire. We acknowledge that these incidents do not fall for consideration within the ambit of the VE Act, but recognise that argument could be made that such events may have resulted in Mr McDonell having developed a psychiatric condition as a consequence of such experiences, with such a condition being clinically worsened as a consequence of experiencing other stressors during periods of operational and/or defence service. In analysis, we observe that Mr McDonell detailed that he felt traumatised by the experiences, but that they had no residual effect on either his mood, ongoing behaviour or emotional wellbeing. In such circumstances and mindful of the various psychiatric opinions, we conclude that such events did not give rise to a defined psychiatric disorder. Such finding we make on grounds of reasonable satisfaction.
83. In turning to his periods of operational service in May 1969 and November 1972, during which there is material pointing to Mr McDonell feeling very frightened and thinking that he was going to die as a consequence of scare charge explosions, we are mindful that Mr McDonell was aware that scare chare explosions were to occur as part of the ship’s measures deployed to prevent potential enemy aggression (Operation Awkward). We acknowledge that the material points to Mr McDonell being unaware as to the timing of the first scare charge detonation, nor the timing of subsequent detonations. In summary we consider that the material points to Mr McDonell’s perception of a situation, with at no stage there being objective material pointing to a life threatening event at any stage (either start, during or at the end) having occurred. In such circumstances the material does not point to Mr McDonell experiencing either a category 1A stressor or a category 1B stressor.
84. In addressing the later catapult incident on HMAS Melbourne, we note that this occurred during a period of defence service, and that any finding must be made on grounds of reasonable satisfaction. Careful examination of the material reveals that Mr McDonell did not witness the event as his workstation was one level below the flight deck and without a view of the incident, and the pilot was neither killed nor injured. In such circumstances, we conclude on the balance of probabilities that Mr McDonell did not experience a category 1A, 1B or category 2 stressor as a consequence of this incident.
85. In addressing the remaining elements within each of the factors nominated, we acknowledge that each has a time factor nominated between the incident and the clinical onset of a depressive disorder. We are mindful that the clinical onset of a disorder is the point in time at which a clinician is able to identify by pointing to material/clinical features which is consistent with the diagnostic criteria for such a disorder. In this instance, the disorder is depressive disorder, which is defined to include depressive episode and dysthymia, the diagnostic criteria for each being nominated in the nominated SoP (Lees v Repatriation Commission (2002) 125 FCR 331, considered and applied).
86. In this matter we have detailed both Mr McDonell’s immediate response to the various incidents and in particular to those experienced during operational service, as well as the symptomatology detailed by Mr McDonell subsequent to the incidents. We observe that such material points to Mr McDonell considering himself “a basket case”, “couldn’t think properly”, “was nervous”, “got mind traffic”, “was scared, anxious and not wanting to go into machinery spaces” and “slept on deck” after experiencing the May 1969 incident, and with such symptoms also being in evidence after the November 1972 incident. We also note that the material points to him describing himself as being less sociable, being fairly withdrawn, suffering nightmares, suffering tension headaches in 1973, while drinking heavily and becoming more aggressive, with binge drinking behaviour evident in Singapore after the May 1969 incident. Further we acknowledge that apart from such complaints, the material points to Mr McDonell maintaining a satisfactory naval career, with promotion until his discharge in 1976. Further, we note no development of a sustained pattern of symptoms is pointed to by the material until circa 1999, a time at which Drs Dinnen, Lewin and Professor Mattick believed there was material pointing to the diagnosis of a psychiatric disorder being able to be definitively made, with Dr Dinnen believing the origins to be in Mr McDonell’s service, but without the clinical symptomatology to support such a clinical onset. We observe that Dr Knox in his opinion remains generalised, with material nominated by him not pointing particularly to any point in time. We also note that Drs Altman and Koller, while detailing symptomatology (Dr Altman only), arrive at different conclusions with depression making a variable contribution to the clinical picture.
87. In considering such raised facts and the diagnostic criteria nominated in the SoP for depressive disorder, we note that the material does not point to Mr McDonell experiencing sufficient diagnostic symptoms within five years of his periods of operational service of:
(1) either a depressed mood or loss of interest or pleasure, with symptoms that have been present for the same two week period and represent a change from previous functioning. Such symptoms include five of the following:
(a)depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g. feels sad or empty) or observation made by others (e.g. appears tearful)
(b)markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by self or by observation of others)
(c)significant weight loss, or decrease or increase in appetite
(d)insomnia or hypersomnia nearly every day
(e)psychomotor retardation or agitation as observed by others
(f)feelings of worthlessness or excessive or inappropriate guilt nearly every day
(g)diminished ability to think or concentrate, or indecisiveness, nearly every day
(h)recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan
……….
(2) (a) Further such symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
All such symptoms relate to some of the criteria for the diagnosis of a major depressive episode.
88. We also observe that the material does not point to Mr McDonell experiencing the following symptoms:
(1) depressed mood for most of the day, for more days than not, over a period of two years
(2) presence, while depressed, of two or more of the following:
(a) poor appetite or overeating
(b) insomnia or hypersomnia
(c) low energy or fatigue
(d) low self-esteem
(e) poor concentration or difficulty making decisions
(f) feelings of hopelessness
(3) during the two year period the person has not been free of symptoms nominated in (1) and (2) for more than two months at a time
……….
(8) the symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning
All such symptoms relate to some of the criteria for the diagnosis of dysthymic disorder as nominated in the SoP.
89. In summary, we conclude that the raised facts do not point to the clinical onset of depressive disorder within five years of experiencing a category 1A or 1B stressor or within one year of a category 2 stressor. As a consequence of our analysis of the material, the clinical onset of the depressive disorder is raised by the material at being circa 1999, this being consistent with material nominated in the clinical opinions of Drs Lewin, Dinnen and Professor Mattick.
90. In such circumstances, we conclude that the hypothesis raised by the material is not a reasonable hypothesis as there is not material pointing to and congruent with each element of the factors considered and nominated in SoP Instrument No. 27 of 2008 concerning depressive disorder.
91. As alluded to earlier in this decision and for the sake of completeness at this point, we have already concluded on the balance of probabilities that the non-operational and defence service incidents did not give rise to a psychiatric condition. With such a finding, any consideration of clinical worsening arising from such incidents, or indeed from the operational service incidents is not relevant to the analysis.
92. With such a finding of fact that a reasonable hypothesis does not exist, it cannot be said that Mr McDonell’s depressive disorder is related to his service, when considered within the ambit of SoP Instrument No. 27 of 2008.
93. In addressing the SoP in existence at the time of the application and primary decision, we note that the relevant SoP is Instrument No. 58 of 1998 concerning depressive disorder. We observe that the diagnostic criteria remain essentially unchanged for major depressive disorder and dysthymic disorder, with the criteria nominated being extracted from DSM-IV. We do note, however, that the relevant factors nominated within paragraph 5 of that Instrument refer to experiencing a severe psychosocial stressor within two years before the clinical onset of depressive disorder.
94. We acknowledge the definition of “severe psychosocial stressor” contained within Instrument No. 58 of 1998:
… means an identifiable occurrence that evokes feelings of substantial distress in an individual, for example being shot at, death or serious illness of a close friend or relative, assault (including sexual assault), severe illness or injury, experiencing a loss such as divorce or separation, loss of employment, major financial problems or legal problems.
95. We have already detailed both the eligible and non-eligible identifiable occurrences experienced by Mr McDonell during his service. As to whether such incidents evoked in Mr McDonell feelings of substantial distress is a question of whether the material points to such when considering the incidents which occurred during operational service, or whether or not on the balance of probabilities during defence service or non-operational service. Leaving to one side the issue as to whether the operational service incidents were identifiable occurrences, within the class of occurrences nominated, the material points to Mr McDonell experiencing feelings of distress for varying periods. As to whether it was substantial is a question of whether the material raises facts about the length of such distress and the effect of the distress in relation to the response to the stress as measured by an individual’s action, and whether or not an ability to maintain functioning is sustained. In the material before us we consider the raised facts from the two operational incidents do not give rise to an identifiable occurrence that falls within the class of listed occurrences, nor does the material point to Mr McDonell experiencing feelings of substantial distress (White v Repatriation Commission (2004) 39 AAR 67, considered and followed). The analysis in relation to the non-eligible incidents does in our view point to Mr McDonell experiencing an identifiable occurrence when considered in the class of occurrences nominated (boiler incident, sexual assault on HMAS Queenborough) and the Melbourne/Evans collision. Nevertheless, the material in evidence in our view does not point to Mr McDonell experiencing substantial distress, both findings being on the balance of probabilities.
96. More importantly in our analysis, we again are reminded, and for reasons clearly defined in our discussions of the current SoP, that the material does not point to the clinical onset of depression being within five years let alone two years of a relevant incident.
97. In such circumstances we conclude that Mr McDonell’s case is not advanced by consideration of an earlier relevant SoP, namely Instrument No. 58 of 1998. Consideration of such does not result in a finding of fact that there is a reasonable hypothesis linking Mr McDonell’s condition of depressive disorder with an aspect of his service. In so stating it is evident that the issue of incongruence relates to the material not pointing to the clinical onset of depressive disorder within a period of two years.
98. In such circumstances we are unable to conclude that Mr McDonell’s condition of depressive disorder can be accepted as a war-caused psychiatric disease.
clinical worsening of depressive disorder
99. This is a matter raised and decided in Mr McDonell’s favour by the VRB in their decision of 11 July 2006. We note that the condition of pleural plaques was accepted as a war-caused disease by the Repatriation Commission on 10 June 2005. We note the material in evidence before the VRB. We also note that in our earlier considerations, we took into account the opinions of Drs Dinnen, Lewin and Professor Mattick that the clinical onset of the depressive disorder was pointed to by the material as occurring in 1999 at the time of Mr McDonell’s first separation from Blackwoods. We also concluded earlier in this decision that Mr McDonell has continued to suffer from depressive disorder. The hypothesis postulated is that Mr McDonell’s depressive disorder clinically worsened at the time he was made aware that he was suffering from pleural plaques in early 2005, after an MRI scan following bowel perforation during an investigation of his irritable bowel syndrome.
100. We observe that Mr McDonell was aware of the possibility that he may suffer an asbestos-related condition prior to being told of the pleural plaques in February 2005, as he had been “a lagger”. Nevertheless he has described his responses when being told of the condition, that he became devastated and frightened, and that he feared he would develop mesothelioma.
101. We are mindful that we have already concluded that Mr McDonell has symptoms consistent with a diagnosis of depressive disorder, with the clinical onset of such a disorder circa 1999/2000. On the evidence presented, we are satisfied that there was an aggravation of this disorder in 2005 subsequent to being advised of the pleural plaque condition. In so finding, we rely upon the opinions of Drs Dinnen, Knox and Altman. Further, we observe that there is evidence indicating continuance of the depressive disorder with the aggravation contributing more than deminimis to such continuation, such a finding being made on grounds of reasonable satisfaction.
102. In so finding, we note that Dr Knox considered that the events around the pleural plaques may have made some contribution to the clinical worsening of his depressive disorder. Dr Dinnen is more particular in stating that his condition was significantly worsened after the discovery of pleural plaques. Dr Lewin believes there has been no worsening in his psychiatric condition, since diagnosis in 1999 or 2001. Professor Mattick is of similar opinion to Dr Lewin, while Dr Altman stated that he was aware of some increase in anxiety symptoms at the relevant time, but unaware that Mr McDonell had made a claim for depressive disorder. Dr Altman’s clinical notes appeared to be silent on the issue.
103. In such circumstances, we conclude that in the situation where a pre-existing condition, namely depression, has been aggravated by the circumstances of a war-caused injury, the condition, namely depression, is a war-caused disease pursuant to section 9 of the VE Act. We so find.
104. In the alternate and in the face of the material adduced, we again turn to the issue of whether the material points to Mr McDonell experiencing a category 1A, 1B or category 2 stressor (SoP Instrument No. 27 of 2008) or a psychosocial stressor (SoP Instrument No. 58 of 1998). In considering the issue of Mr McDonell being told of the pleural plaques, the material points to circumstances that could be considered life threatening, with the responses as described by Mr McDonell pointing to substantial distress. In such circumstances we consider that the material does point to Mr McDonell experiencing a life threatening event and a psychosocial stressor. We have already indicated that there is material pointing to a clinical worsening of depressive disorder within days/weeks of knowledge of the pleural plaques.
105. In such circumstances we find that a reasonable hypothesis exists linking Mr McDonell’s pleural plaques (war-caused) to a clinical worsening of his depressive disorder in that the material points to and is congruent with each element of factor 6(d) of SoP Instrument No. 27 of 2008 or factor 5(f) of SoP Instrument No. 58 of 1998, both concerning depressive disorder.
106. While there is material pointing to no clinical worsening of the condition of depressive disorder as a consequence of the pleural plaques (opinions of Dr Lewin and Professor Mattick, as well as a less than enthusiastic verbal endorsement from Dr Altman), we conclude that a finding of the absence of clinical worsening of the depressive disorder in such circumstances cannot be made beyond reasonable doubt, with the consequence that the reasonable hypothesis finding is not disturbed.
107. It is for these reasons that we affirm the decision of the VRB of 11 July 2006 as regards this aspect.
generalised anxiety disorder
108. For the condition of generalised anxiety disorder to be related to relevant service there must as a minimum exist before it can be said that a reasonable hypothesis has been raised, a factor connecting generalised anxiety disorder with the circumstances of Mr McDonell’s service.
109. The relevant SoP for operational service is Instrument No. 101 of 2007 concerning anxiety disorder, which is defined within paragraph 3 of the Instrument to include generalised anxiety disorder.
110. The relevant factors listed within paragraph 6 of the Instrument are identical with that listed earlier for depressive disorder, with the only difference being generalised anxiety disorder replaces depressive disorder.
111. Factors 6(a)(ii) and 6(a)(iii) relate to experiencing a category 1A stressor or category 1B stressor within the five years before the clinical onset of anxiety disorder, while factor 6(a)(v) refers to experiencing a category 2 stressor within one year before the clinical onset of anxiety disorder, and factor 6(a)(vi) details having a clinically significant psychiatric condition within ten years before the clinical onset of anxiety disorder. Factor 6(c) is concerned with issues of clinical worsening. We note that definitions within paragraph 9 for category 1A, 1B and 2 stressors, and a clinically significant psychiatric condition remain congruent with that nominated for depressive disorder.
112. Consideration of this issue is identical in terms of both the underlying material and the analysis thereof with our consideration of depressive disorder. It is not our intention to repeat such considerations, but only highlight any extra relevant material.
113. There is material pointing to Mr McDonell being a worrier and apprehensive as a child and adolescent prior to joining the navy, this being a personality trait that evolved and continued through his life. This takes our analysis again to the issue of the clinical onset of the anxiety disorder and the concurrent issue of whether there is material pointing to Mr McDonell experiencing any particular service-related stressor.
114. The issue and consideration of whether Mr McDonell experienced particular kinds of stressors has been detailed earlier. There is no variation in that analysis either as it relates to non-eligible service stressors or eligible service stressors.
115. The issue of whether the material points to the clinical onset of anxiety disorder within five years of experiencing a particular type of stressor requires the same analysis which has already been discussed in relation to depressive disorder. The outcome of our consideration in relation to anxiety disorder is identical with that for depressive disorder in that there is no material pointing to the clinical onset of anxiety disorder occurring within five years of experiencing a stressor (one year for a category 2 stressor). While Dr Dinnen has a particular belief that the anxiety disorder is related to service, he was particular that the clinical onset of any psychiatric disorder could not be made until the mid nineties, the point of time at which clinical material permits such a diagnosis to be made. We consider that the material before us does not point to Mr McDonell describing the following symptomatology within five years of the service incidents:
A. Excessive anxiety and worry (apprehensive expectation), which occur on more days than not for a continuous period of at least six months, about a number of events or activities; and
B. The person finds it difficult to control the worry; and
C. The anxiety and worry are associated with three or more of the following six symptoms, with at least some symptoms present for more days than not during the previous six month period:
(1) restlessness or feeling keyed up or on edge
(2) being easily fatigued
(3) difficulty concentrating or mind going blank
(4) irritability
(5) muscle tension
(6) difficulty falling or staying asleep, or restless unsatisfying sleep; and
D. The focus of the anxiety and worry is not confined to features of any other Axis I disorder; and
E. The anxiety, worry, or physical symptoms (as described in C. above) cause clinically significant distress or impairment in social, occupational, or other important areas of functioning; and
F. The anxiety and worry are not due to the direct physiological effects of a substance or a general medical condition and do not occur exclusively during a mood disorder, a psychotic disorder, or a pervasive developmental disorder; ……
116. In such circumstances, we conclude that the postulated hypothesis relating to Mr McDonell’s anxiety disorder with his service is not a reasonable hypothesis as the material before us does not point to and is not congruent with each element of any factor nominated within the Instrument No. 101 of 2007. Further, and for similar reasoning, we conclude there is no material pointing to a clinical worsening of a pre-existing psychiatric disorder or a psychiatric disorder arising from an incident experienced during non-eligible service.
117. In addressing an earlier SoP, namely Instrument No. 1 of 2000 concerning generalised anxiety disorder, this being the SoP in existence at the time of application and primary decision, we note that the Instrument raises the issue of experiencing a severe psychosocial stressor, which is defined in identical terms as detailed in our consideration of Instrument No. 58 of 1998 concerning depressive disorder. Further, we note that the time factor between experiencing the named stressor and the clinical onset of anxiety disorder is two years, as it is for having a clinically significant psychiatric condition or a clinical worsening.
118. Again, and for reasons nominated in our earlier consideration of the current SoP concerning anxiety disorder and also in relation to our earlier consideration of SoP Instrument No. 58 of 1998 concerning depressive disorder, a reasonable hypothesis cannot exist for the very same reasons that the material does not point to the clinical onset of anxiety disorder occurring within two years, if indeed Mr McDonell had suffered a psychosocial stressor – a finding we are disinclined to consider having been pointed to by the material before us.
119. In summary, Mr McDonell’s condition of generalised anxiety disorder cannot be accepted as a war-caused psychiatric condition, with consideration of both current and primary decision SoPs concerning anxiety disorder failing to establish a reasonable hypothesis linking the condition with an aspect of service.
alcohol abuse / dependence
120. We are mindful that careful and detailed clinical histories of alcohol consumption have been given to and recorded by the specialist clinicians in this matter. It is relevant to us that the material before us points to Mr McDonell detailing symptomatology which the various specialists consider satisfies the diagnostic criteria for the clinical onset of alcohol abuse to have occurred in 1971/1972. In this regard there is material pointing to Mr McDonell experiencing a maladaptive pattern of alcohol use leading to clinically significant impairment or distress as manifested by:
(a) a recurrent use of alcohol resulting in a failure to fulfil major role obligations at work or at home (failure to attend at work on time)
(b) continued alcohol use despite having persistent or recurrent social or interpersonal problems (aggression and fighting at and around hotels, arguments with fiancée/wife)
121. Further we note that such a date of clinical onset of alcohol abuse is supported by both Dr Dinnen and Professor Mattick.
122. We also observe that the material points to Mr McDonell having some clinical symptoms of alcohol dependency while at HMAS Nirimba in 1971-1972, with the material before us pointing to the clinical onset of alcohol dependence in the early 1980s (opinion of Dr Dinnen, Professor Mattick, while the other clinicians have not defined a date of clinical onset).
123. The relevant SoP is Instrument No. 17 of 2008, concerning alcohol dependence and alcohol abuse. The relevant factors in this matter are contained within paragraph 6:
(a) having a clinically significant psychiatric condition at the time of the clinical onset of alcohol dependence or alcohol abuse; or
(b) experiencing a category 1A stressor within the five years before the clinical onset of alcohol dependence or alcohol abuse; or
(c) experiencing a category 1B stressor within the five years before the clinical onset of alcohol dependence or alcohol abuse; or
(d) experiencing the death of a significant other within the two years before the clinical onset of alcohol dependence or alcohol abuse; or
(e) having a clinically significant psychiatric condition at the time of the clinical worsening of alcohol dependence or alcohol abuse; or
(f) experiencing a category 1A stressor within the five years before the clinical worsening of alcohol dependence or alcohol abuse; or
(g) experiencing a category 1B stressor within the five years before the clinical worsening of alcohol dependence or alcohol abuse; ……
124. The definitions contained within paragraph 9 of the Instrument for clinically significant psychiatric condition, category 1A stressor, and category 1B stressor, are essentially consistent with what was detailed when considering depressive disorder. In relation to the incidents of eligible service, the material before us points to a consideration of experiencing a life threatening event (category 1A stressor). In relation to the non-eligible service, the material points to the issue of experiencing sexual molestation (category 1A stressor) and viewing corpses as an eyewitness (category 1B stressor) with, as for psychosocial stressors, the event must have an objective element of being life threatening, not just someone believing it may be life threatening.
125. In addressing the issue of whether the material points to Mr McDonell experiencing a life threatening event, we again reiterate our earlier consideration that the material points to Mr McDonell perceiving that the events he was experiencing in May 1969 and November 1972 were life threatening, whereas the material points objectively to Mr McDonell experiencing an event which was not life threatening at the start, during the event or at the conclusion of the event. Further, we observe that the material does not point to Mr McDonell having a clinically significant psychiatric disease at the time of the clinical onset of alcohol abuse/dependence.
126. The material does detail circumstances during Mr McDonell’s non-eligible period of service that could be considered category 1A, or 1B stressors. Such experiences include the sexual molestation on HMAS Queenborough (category 1A) and viewing corpses as an eyewitness on HMAS Queenborough (category 1B). On the balance of probabilities, we consider that Mr McDonell did experience category 1A and category 1B stressors during periods of ineligible service.
127. In addressing whether a reasonable hypothesis exists we observe that the material does not point to Mr McDonell experiencing neither a category 1A nor category 1B stressor during his periods of operational service, nor is there material pointing to Mr McDonell having a clinically significant psychiatric condition at the time of the clinical onset of alcohol abuse/dependence. In such circumstances, we conclude as a finding of fact that a reasonable hypothesis has not been established connecting Mr McDonell’s condition of alcohol dependence or alcohol abuse with the circumstances of his service. Also in the circumstances where an hypothesis which relies upon experiencing either a category 1A or 1B stressor before the clinical worsening of the condition, we conclude that a reasonable hypothesis cannot be found to exist in the absence of material pointing to the relevant element of the factor.
128. Again, for the sake of completeness, we conclude on the balance of probabilities that Mr McDonell did not experience either a category 1A or 1B stressor during his period of defence service on HMAS Melbourne in relation to the catapult incident, and again for reasons detailed earlier in this decision.
129. In summary, while we have concluded that there is material pointing to the clinical onset of alcohol abuse in 1971/72, and alcohol dependence in the early 1980s, in the absence of a reasonable hypothesis being established, which connects Mr McDonell’s alcohol abuse/dependence with his periods of service, we conclude, pursuant to a consideration of SoP Instrument No. 17 of 2008, that his claim in relation to alcohol abuse/dependence must fail.
130. In addressing the same issues within the context of an earlier SoP, namely Instrument No. 76 of 1998 (this being the SoP at the time of the primary decision in this matter), we note the SoP contains similar diagnostic criteria for the diagnosis of both alcohol abuse and alcohol dependence as the current SoP. In relation to the factors we observe that the time frame between experiencing a severe stressor and the clinical onset of either alcohol abuse or dependence is two years.
131. We note the definition of experiencing a severe stressor contained within paragraph 8 of Instrument No. 76 of 1998
“experiencing a severe stressor” means, the person experienced, witnessed or was confronted with, an event or events that involved actual or threat of death or serious injury, or a threat to the person’s or other people’s physical integrity, which event or events might evoke intense fear, helplessness or horror.
In the setting of service in the Defence Forces, or other service where the Veterans’ Entitlements Act applies, events that qualify as severe stressors include:
(i) threat of serious injury or death; or
(ii) engagement with the enemy; or
(iii) witnessing casualties or participation in or observation of casualty clearance, atrocities or abusive violence; ……
132. In considering the material before us, we observe that there is no material pointing to Mr McDonell suffering from an Axis I or II psychiatric disorder. Further we note that the material points to Mr McDonell experiencing two events during his operational service (the scare charge episodes in May 1969 and November 1972) that in Mr McDonell’s perception involved actual or threat of death or serious injury or a threat to the person’s or other people’s personal integrity. The material points to Mr McDonell perceiving that on both occasions, with his response being clearly identified of being frightened and in fear of his life, yet continuing to remain at his station, make inquiries as to the cause of the event and continue to undertake his duties. We observe that the material outlined does not point to Mr McDonell’s response to the said events being one of intense fear, helplessness and horror, and in particular the second incident in November 1972 was when armed with knowledge of his prior experience.
133. In the absence of material pointing to intense fear, helplessness and horror, we conclude that a reasonable hypothesis does not exist to connect Mr McDonell’s conditions of alcohol abuse/dependence with his periods of operational service either by way of having a psychiatric illness at the time of clinical onset or experiencing a severe stressor within two years prior to the clinical onset of alcohol abuse/dependence. In so finding, we observe that the material does not point to and be congruent with each element of the factor.
134. In summary, Mr McDonell’s condition of alcohol abuse/dependence cannot be accepted as a war-caused condition, with consideration of both current and primary decision SoPs concerning alcohol abuse/dependence failing to establish a reasonable hypothesis linking the condition with an aspect of service either by way of having a prior psychiatric disease or experiencing various types of stressors, as defined within the relevant SoPs.
irritable bowel syndrome
135. This was one condition which remained before us. On the review of the material before us, including the opinion of a gastroenterologist, Dr Anthony Clarke, we are satisfied on the balance of probabilities that Mr McDonell does suffer from irritable bowel syndrome.
136. Further we observe that the material points to Mr McDonell’s main symptom being one of flatulence that has been present since about 1995; that he had no episodes of severe diarrhoea while in the navy; that there has been some instability of bowel habit and some increased frequency. We observe that Dr Clarke considers that the clinical onset of the condition was in 1995.
137. We note that the relevant SoPs for this condition is Instrument No. 103 of 1996 (operational service) and Instrument No. 104 of 1996 (defence service). We observe that Mr McDonell relies upon factor 5(b), namely “suffering a specified psychiatric condition within the six months immediately before the clinical onset of irritable bowel syndrome.” We note that a specified psychiatric condition is defined within paragraph 7 to include a psychiatric condition with features of anxiety or a psychiatric condition with depressive features.
138. In the absence of material pointing to the clinical onset of a specified psychiatric condition during his periods of operational and/or his defence service, we conclude that there is not a reasonable hypothesis raised connecting Mr McDonell’s irritable bowel syndrome with his periods of operational service, and for his defence service we make a similar finding on the balance of probabilities.
139. In such circumstances, we find that Mr McDonell’s claim that his irritable bowel syndrome was a war-caused disease must fail.
conclusion
140. In summary finding, we conclude that the decision under review be set aside in relation to the condition of xeroderma, which is found to be a war-caused disease, while the remainder of the decision is affirmed. Further, the matter is remitted for assessment, if such an assessment has not already been done, with date of effect being 13 April 2004.
decision
141. We set aside the reviewable decision, in part, finding the applicant does suffer war-caused xeroderma. We affirm the remainder of the decision that the applicant does suffer war-caused depressive disorder but not post traumatic stress disorder, alcohol dependence, irritable bowel syndrome and generalised anxiety disorder. We also remit the matter for assessment, if such an assessment has not already been done, with date of effect being 13 April 2004.
I certify that the 141 preceding paragraphs are a true copy of the reasons for the decision herein of Ms Robin Hunt, Senior Member and Dr John Campbell, Member
Signed: ..........................[Sgd]..........................
Jennifer Wong, AssociateDate/s of Hearing: 12-13 April, 30 August & 1 November 2007
Date of Decision: 15 July 2008
Counsel for the Applicant: Ms E WoodAdvocate for the Applicant: Legal Aid Commission – Veterans’ Advocacy Service
Counsel for the Respondent: Mr G Purcell
Advocate for the Respondent: Department of Veterans’ Affairs
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