Thompson and Repatriation Commission - [2000] AATA 635

DECISION AND REASONS FOR DECISION [2000] AATA 635

ADMINISTRATIVE APPEALS TRIBUNAL )

) No V1998/1289

VETERANS' AFFAIRS DIVISION )
           Re      ELLA MAY THOMPSON
  Applicant
           And     REPATRIATION COMMISSION
  Respondent

DECISION

Tribunal Mrs Joan Dwyer, Senior Member Mr I Campbell, Member Dr P Fricker, Member

Date2 August 2000
PlaceMelbourne

Decision        The Tribunal sets aside the decision of the Veterans' Review Board of 30 September 1998 and in substitution varies the decision of the Repatriation Commission made 17 October 1997 to provide: 1. Psychoactive substance abuse or dependence, alcoholic diarrhoea, gastro-oesophageal reflux disease and acquired cataracts are war-caused diseases within the meaning of that term in s 9 of the Veterans' Entitlements Act 1986 ("the Act") with effect from 24 December 1996. 2. Mrs Thompson is entitled to pension at 90% of the General Rate from 24 December 1996.
  (Sgnd) Joan Dwyer
  Senior Member
VETERANS' AFFAIRS – whether psychoactive substance abuse or dependence and post-traumatic stress disorder are war-caused diseases – whether service as a driver at East Sale Air Base during a period when approximately 120 aircrew were killed in plane crashes constitutes a "severely stressful event" or "experiencing a stressor" – whether veteran confronted with the plane crashes – whether veteran suffering irritable bowel syndrome or alcoholic diarrhoea – whether alcoholic diarrhoea and gastro-oesophageal reflux disease are war-caused diseases – assessment of rate of pension – decision set aside
WORDS AND PHRASES – "severely stressful event", "experiencing a stressor", being "confronted with an event"
PRACTICE AND PROCEDURE – need to put full material before psychiatrist – failure to provide psychiatrist called by respondent with report as to number of deaths and air crashes at East Sale Air Base during relevant period
Suggestion that the reasons of the Tribunal including excerpts from evidence of a senior gastroenterological surgeon be forwarded to Repatriation Medical Authority as it may like to review SoP for irritable bowel syndrome on basis of his opinion
Veterans' Entitlements Act 1986 s 120(4)

Keeley v Repatriation Commission (1999) 56 ALD 455

Repatriation Commission v Keeley [2000] FCA 532

Re Budworthand Repatriation Commission [2000] AATA 127

Re Slattery and Repatriation Commission (AAT 427, 16 June 1998

Re Clarke and Repatriation Commission [2000] AATA 545

REASONS FOR DECISION

2 August 2000 Mrs Joan Dwyer, Senior Member Mr I Campbell, Member Dr P Fricker, Member

This is an application for review of a decision of the Repatriation Commission ("the Commission") made 17 October 1997 (T28) and affirmed by the Veterans' Review Board ("the VRB") on 30 September 1998.
At the hearing Mr D De Marchi, a solicitor, appeared for Mrs Thompson. Mr B Lilley, a solicitor, appeared for the Commission. The Tribunal had before it the documents ("the T documents") lodged pursuant to s 37 of the Administrative Appeals Tribunal Act 1975 ("the AAT Act") and the exhibits tendered during the hearing. Mrs Thompson gave evidence. Evidence on her behalf was also given by Mr Marshall, a gastroenterological surgeon, and Dr Cole, a psychiatrist. The respondent called Dr Strauss, a psychiatrist, and Dr Luke Murphy, a consultant physician.
On 25 March 1997 Mrs Thompson lodged a claim to have certain conditions accepted as war-caused diseases. The conditions which are still relevant are "substance abuse", post traumatic stress disorder ("PTSD"), which Mrs Thompson claimed was attributable to "stress of service transporting injured and sick personnel" and "throat, stomach and gullet", which she claimed was attributable to service related smoking. Mrs Thompson's claim for acquired cataracts was lodged at the same time and was accepted by the Commission in its decision of 17 October 1997. The Commission granted disability pension at 40% of the General Rate with effect from 24 December 1996, in respect of the eye condition.
Mrs Thompson served with the Royal Australian Air Force ("RAAF") from 29 November 1943 to 20 September 1946. She served within Australia and her service is eligible war service as that term is defined in s 7 of the Veterans' Entitlements Act 1986 ("the Act").
Accordingly the question whether the claimed conditions are war-caused within the meaning of that term in s 9 of the Act, is to be decided on the standard of proof in s 120(4) of the Act which provides:
120 Standard of proof
. . . .
(4)Except in making a determination to which subsection (1) or (2) applies, the Commission shall, in making any determination or decision in respect of a matter arising under this Act or the regulations, including the assessment or re-assessment of the rate of a pension granted under Part II or Part IV, decide the matter to its reasonable satisfaction.
Note:This subsection is affected by section 120B.
There are Statements of Principle ("SoPs") in respect of "PTSD" and psychoactive substance abuse or dependence. The effect of s 120B is that the Tribunal is to be reasonably satisfied that those diseases are war-caused only if the material before the Tribunal raises a connection between the disease and some particular service rendered by the person, and the relevant SoP upholds the contention that the disease is, on the balance of probabilities, connected with that service.
The Federal Court has held in Keeley v Repatriation Commission (1999) 56 ALD 455 and in Repatriation Commission v Keeley [2000] FCA 532, that a claim is to be determined in accordance with the SoP which was in force at the time of the original determination of the Commission as to whether or not a claimed condition was war-caused.
psychoactive substance abuse or dependence
There is no dispute about the fact that Mrs Thompson does suffer from psychoactive substance abuse or dependence. We therefore propose, first, to consider whether or not that condition is war-caused. The original determination of the Commission was made on 17 October 1997. Thus, in accordance with the decisions of the Federal Court in Keeley, Instrument No. 6 of 1994 is the relevant SoP. It came into force on 8 September 1994 and remained in effect until 1 December 1998 when it was revoked by Instrument No. 77 of 1998.
The relevant SoP for psychoactive substance abuse or dependence, in paragraph 1, specifies two factors which must exist before it can be said that on the balance of probabilities psychoactive substance abuse is connected with the circumstances of a veteran's service. That paragraph provides:
1.Being of the view that, on the sound medical-scientific evidence available to the Repatriation Medical Authority, it is more probable than not that psychoactive substance abuse or dependence and death from psychoactive substance abuse can be related to eligible war service (other than operational service) rendered by veterans and defence service (other than hazardous service) rendered by members of the Forces, the Repatriation Medical Authority determines, under subsection 196B(3) of the Veterans' Entitlements Act 1986, that the factors that must exist before it can be said that, on the balance of probabilities, psychoactive substance abuse or dependence or death from psychoactive substance abuse or dependence is connected with the circumstances of that service, are:
(a)a severely stressful event immediately prior to the clinical onset of psychoactive substance abuse or dependence, and maintaining the abuse or dependence post-service; or
(b)a psychiatric condition prior to the clinical onset of psychoactive substance abuse or dependence; or
. . .

Paragraph 2 provides that the relevant factor must be related to service rendered by the person.

The concept of a "severely stressful event" is defined in paragraph 4 of the SoP as follows:
"severely stressful event" means a psychologically distressing event that is outside the range of usual human experience (that is, outside the range of common experiences such as simple bereavement, chronic illness, business losses and marital conflict). Such events could include natural disasters (for example devastating floods or earthquakes), accidental disasters (such as car accidents with resulted in serious physical injury to a person), deliberately caused disasters (such as bombing) and torture.
The stressful event on which Mrs Thompson relies, is her service as a driver at East Sale Air Base ("Sale Air Base") where she served from 6 January 1944 to 5 May 1946 (A7). So far as the evidence reveals the first time when Mrs Thompson described stressful events during her service was in a consultation with Dr Parkin, a psychiatrist, in February 1998. Mrs Thompson saw the psychiatrist, Dr Smith, in June 1997 and a physician, Dr Murphy, in July 1997. Both appointments were arranged by the Department of Veterans' Affairs. She did not give either of those specialists any account of stressful events during her service, other than the personal discipline and regimentation and hours of shift work during service.
Dr Parkin wrote that when he had started taking a history of possible PTSD in February 1998, Mrs Thompson revealed that she had been involved in driving student pilots to their planes at the Sale Air Base. He wrote in his report (T32 p86-106):
She told me that many of them were killed and when I asked her how many she was unable to quantify. She said that the place was nicknamed "Death Valley." She felt horrified by these deaths. One of the officers gave her a dog to look after just in case he got killed and when he was killed she then continued to look after the dog until a few days later an MP shot it. She feels that she could have shot the MP as she had made a commitment to this particular officer. All of this comes back to her in the form of nightmares and does worry her occasionally but not often enough during her waking moments to warrant accepting this as one of the criteria.

Dr Parkin added in his report:

She described how her drinking started in East Sale when she was taken into a pub by the girls and given a shandy which she thought was a soft drink. The more she had the better she felt. This relieved the stresses that she was experiencing on the base and she became increasingly involved in drinking heavily. She started getting drink through her wheeling and dealing with people who wanted favours done such as dry cleaning dropped off and things like that.

In concluding his report Dr Parkin commented that Mrs Thompson had not mentioned some of these issues before. He wrote that she explained to him that her failure to mention those matters was related to the distress it caused her.

In March 1998 Mrs Thompson also saw Mr Dumbrell, a general surgeon. She again told him that she started drinking during her time in the service, and had found that alcohol relieved her tensions and quickly became a heavy drinker. Mr Dumbrell wrote (T33 p108):
Specifically she was disturbed by the fact that she was driving student pilots to their planes at the air base, many of whom went on to be killed. She has had nightmares intermittently about this ever since her service. She has remained a heavy drinker and by her own admission has become a chronic alcoholic.
This matter was listed for hearing on 5 October 1999, but the evidence did not commence that day. Before the hearing resumed (with a reconstituted Tribunal as one Member had ceased to be available) the Tribunal arranged for the District Registrar to write to the parties asking for a report from a military historian as to the number of air crew killed or injured in plane crashes from RAAF Sale, while Mrs Thompson was stationed there. The Tribunal had noticed that the VRB in its decision had written (T34 p124):
[F]or the purposes of the SoP "severely stressful event" means a psychologically distressing event that is outside the range of usual human experience (that is, outside the range of common experiences such as simple bereavement, chronic illness, business losses and marital conflict). Such events could include natural disasters (for example devastating floods or earthquakes), accidental disasters (such as car accidents which resulted in serious physical injury to a person), deliberately caused disasters (such as bombing) and torture. In the Board's opinion hearing of death and aircraft crashes second hand, even having met the persons involved, is not outside the range of common experiences.
The Tribunal had noted the Board's opinion that hearing of deaths and aircraft crashes is not outside the range of common experiences. The Tribunal considered that whether the crashes constituted "a severely stressful event", could depend on facts such as how many people had died in aircraft crashes, how frequent those crashes were, and whether the veteran had any involvement in those crashes or with the people killed. The Tribunal noted that the definition in the SoP does specifically include the example "car accidents which resulted in serious physical injury to a person". The Tribunal considered that aircraft crashes which resulted in death would similarly be capable of being described as "severely stressful events".
When the hearing resumed on 9 May 2000, the respondent had obtained a report from Professor McCarthy (R5). He is an historian at the Australian Defence Force Academy. His report stated that Sale Air Base opened in April 1943 and ceased to operate in 1946. Professor McCarthy wrote that there were no air accidents in 1946, but that between April 1943 and 27 August 1945 an official account states that there were 147 aircraft accidents with the resultant loss of life of 131 aircrew dead or missing. Mrs Thompson was at Sale Air Base for most of that period. She was posted there on 6 January 1944 and remained until May 1946 when the Base was closed, as it was no longer required for the training of pilots. It is difficult to calculate how many of these accidents occurred prior to 6 January 1944. Professor McCarthy wrote that some of the records were missing and he did not itemise each incident. Doing the best we can from his report it seems that perhaps 12 aircrew had been killed during 1943, leaving approximately 120 aircrew to die in accidents while Mrs Thompson was at Sale Air Base.
When Mrs Thompson was posted to Sale Air Base on 6 January 1944, she was aged 18. She said in her evidence that prior to enlistment she had led a sheltered life. She left school at 14 and helped her mother for two years. At age 16 she started work at Prestige Hosiery. She worked for 18 months before enlisting. Her family belonged to the Rechabite Society and did not drink. Mrs Thompson explained that the aim of the Rechabite Society was to abstain from alcohol. She said that she had been very involved as a member of the Junior Lodge and Senior Lodge, until she joined the RAAF. She said she neither drank nor smoked until she joined the RAAF.
Mrs Thompson explained that one of her duties as a driver at Sale Air Base was to pick up aircrew and take them to the parachute section for their parachutes and from there out to the planes. She said she would say "Goodbye, see you later boys". She said it was also her responsibility in most cases to pick up returning aircrew she had taken to the planes, but "lots of times they didn't come back. They crashed." (trans. p15). She said she felt horrified about that. She was asked how often it happened, she replied, "many times". Mrs Thompson explained that she knew the aircrew well. She socialised with them, and was invited to their messes. Quite often she had socialised the night before she would pick them up to take them to their planes. She said, "they were like brothers to me". She explained that she became very upset when they were lost. She said "I couldn't get them out of my mind." When asked "what did you do." She replied " Lay my hands on drink. I felt it eased it" (trans. pp15-16).
Mrs Thompson said that she was never expressly told that a plane had crashed. When that had occurred, she was simply told that she would not need to go out to the airport, or that there was another job for her. She realised that they were not coming back. She said that she knew one aircrew member who survived four crashes. After the crashes "he had no hair, no eyebrows, he was grey where the flames had burnt him, he was just vibrating and talking incoherently" (trans. p17). Before the accident he was just like all the other boys "very happy, very jovial, good fun". Mrs Thompson was shocked. She knew he had been engaged and intending to marry as soon as the war was over and his mind had gone.
Mrs Thompson said that she remembered the first time she was told not to pick up aircrew. The said that she had a card instructing her to go down to the airport. As she pulled out to do so, the Flight Sergeant raced out from transport and yelled out (trans. p69) "Trixie, Trixie, come back", she then said "you don't have to go". Mrs Thompson said that she asked "have they gone elsewhere or have they come down?" The Flight Sergeant just turned around and walked away. Mrs Thompson said that would have happened sometime in 1944, after she had been at the base a few months. She said that particular incident made her numb. She could not believe it, but when it happened again, (trans. p72) "it never got any better. In fact I would say it got worse". Mrs Thompson said that it happened so many times that the unit was nicknamed "Death Valley". They had up to seven crashes a week. She said the average people in the Mess did not know about it, (trans. p72) "it was only those who were intimately involved with the planes and we never talked about it; we were told not to". She said that her Flight Sergeant drilled into all of the drivers not to talk about it.
Mrs Thompson also gave evidence about an officer leaving his dog with her. She said (trans. p17):
Just before he went on the plane he came over to me and he said, Trix, I have a premonition and I have got my darling little dog up there, if anything happens, would you look after it.

She said she would. She said his premonition came true (trans. p17):

. . . and I got the little doggie and I had it at transport hut. I had four days before I was due for leave and I had made arrangements with my parents to take the dog. Two days I had the dog and on the second day the military police shot it.
Did they shoot it in front of you?---No, while I was out working.
And what happened when you came back?---I was told the MPs took the dog and shot it. And I had given that man my promise that I would look after it, that officer. And if I could have put my hands on a gun I would have shot that MP, as God is my judge I would have shot him.

Mrs Thompson was asked "How did you feel about that event?" She replied (trans. p18):
I was shocked, couldn't believe it.
If I might be excused for leading – did you feel helpless about that?---Yes, I couldn't do anything and yet I had given my promise.
Have you ever relived some of these distressing events?---Yes. They have been with me all my life.
. . .
I see a face and it happens repeatedly in a crowd, just somewhere, and it is one of those boys. I have nightmares and sweats, it is very hard to live with it all the time.
Mrs Thompson said (trans. p55) the effects on her became worse as the causalities mounted up. She said that when it became apparent that the airmen were not coming back, she found it devastating and horrifying. She said she was shocked. She could not find enough words to describe how she felt. Mrs Thompson said that she started recollecting the individuals involved in the accidents, and they kept on coming back all the time while she was trying to forget it. She said she dealt with that by drinking more.

Mrs Thompson said that she was married in September 1946, six weeks after her discharge. She and her husband both had drinking problems. She said her husband assaulted her right from the start of the marriage, but that was not the worst problem. The worst problem was trying to cope with her own experiences and rearing children with a husband who was seldom there.
Mrs Thompson said that she knew she had a drinking problem long before her marriage. She told the Tribunal, as she had told Dr Parkin and Mr Dumbrell, that she reacted to the stresses of her services by drinking heavily. She said that the other drivers in her hut would have seen her under the influence. She also said that it was "a close knit little company and if I did come under the influence it was covered".
We find that Mrs Thompson's duties as a driver at the Sale Air Base, commonly known as Death Valley, where she was one of the drivers obliged to drop off and pick up aircrew were psychologically distressing. Approximately 120 of the aircrew driven to the airport in the time Mrs Thompson was posted there were killed in air crashes. It is our opinion that the number of accidents and deaths in the time Mrs Thompson was at Sale Air Base does take her experience outside the range of usual human experience. Further, the fact that she had to drive more aircrew down to the airport, even after there had been a number of such accidents and deaths also adds to the stresses of the service. We find that her service as a driver in those circumstances does constitute a "severely stressful event" as defined in the SoP.
Mr Lilley submitted that even if we were to find that Mrs Thompson's service at Sale Air Base constituted "a severely stressful event", we could not find that it occurred "immediately prior" to the clinical onset of psychoactive substance abuse or dependence.
The relevant SoP defines psychoactive substance abuse or dependence as follows:
"psychoactive substance abuse or dependence" means a maladaptive pattern of use, attracting ICD code 303 or 304, that is indicated by either:
(a)continued use of the substance despite knowledge of having a persistent or recurrent social, occupational, psychological or physical problem that is caused or exacerbated by use of the substance; or
(b)recurrent use of the substance when use is physically hazardous (eg driving while intoxicated);
Mrs Thompson gave evidence as to the commencement of her alcohol habit and subsequent alcohol abuse. She recounted her first experience of drinking explaining that she had been strictly brought up as a member of the Rechabite Lodge and then describing, at trans. p14, the first occasion when she had a drink. She said:
… I was with other transport drivers who were a lot older than me, very hot, it was decided we would all go and have a drink and they stood outside the hotel, and I said, I can't go in there. They said, why not. I said I am a Rechabite. What is that? I said, we don't drink. Don't worry, Trix, you can get a soft drink in here and I was very curious about the working inside a hotel because this – taught – it is rather sin, evil, and I was curious and I wanted to see it. So I was given a drink and it was a beer shandy and I didn't know, I didn't like the taste, I had never tasted alcohol. That was the beginning …..
I didn't like it and I said I don't like this and they said, oh, you have got what you wanted, it was cool, so I drank it and then there were about seven of us and it was a case of all shout a piece, well, as I had more and more of them I was starting to feel wonderful. Relaxed.
As set out in paragraph 18, Mrs Thompson said that once she had found drink made her feel relaxed, she reacted to the events when aircrew were lost by "lay[ing] my hands on drink. I felt it eased it" (trans. p15). She also said that she drank "as much as I could get" (trans. p16). Mrs Thompson said that her drinking increased as the incidents mounted up. She said that she kept on visualising the people who were not coming back. She said she tried to forget them but "they kept coming back all the time". She attempted to avoid those thoughts by drinking more. She said sometimes she was driving with a "mighty hangover" (trans. p57) which made it a little hard to concentrate on driving.
Mrs Thompson said that she knew she had a drinking problem "long before I got married". She said in those days it wasn't easy for a woman to be an alcoholic because people talked about seeing a woman drunk, but not about a man. She said other women drivers saw her under the influence, but she did not see any of them in that state (trans. p75).
Mrs Thompson did not report either her stresses or her drinking to any service medical officer or other doctor. Her service medical records show she attended for treatment for severe headache in July 1945, but contain no mention of psychiatric problems. We consider it not surprising that Mrs Thompson kept her problem to herself. First, the drivers were instructed not to talk about the crashes, secondly to seek treatment for problems due to the crashes would have seemed very self-indulgent during war-time when the aircrew were the ones running the risks. Mrs Thompson said it was not an option to ask to be relieved of the driving duties – "I put my name on the dotted line, and I was told to do it". (trans. p72). As Mrs Thompson said: (trans. p72):
This was a training station, and they had to get the crews through. The Japs were coming down through the island. They were being pushed through their courses as fast as they could.

We find that in those days it would have been very difficult for a young woman, especially one with Mrs Thompson's Rechabite background, to admit to and seek help with a drinking problem.

We accept Mrs Thompson's evidence and find that by the time she left Sale Air Base she had developed "a maladaptive pattern of alcohol use indicated by continued use of alcohol despite knowledge of having a persistent or recurrent social, occupational, psychological or physical problem that is caused or exacerbated by use of the substance". Mrs Thompson said she was trying to get her hands on as much drink as she could get. She tried to keep knowledge of her drinking to herself, but her fellow drivers saw her drunk and covered for her while she was at Sale Air Base. Also she said she went on drinking although it was hard to concentrate on her driving with a hangover. She felt she needed the alcohol to help her try to forget the aircrew who were not coming back. The Federal Court in Repatriation Commission v Gosewinckel [1999] FCA 1273 held that there cannot be a "clinical onset" of a disease before the condition satisfies the requirements of the disease in the SoP. We find that the requirement of psychoactive substance abuse or dependence were satisfied during Mrs Thompson's service at Sale Air Base.
We find that Mrs Thompson did experience a severely stressful event immediately prior to the clinical outset of psychoactive substance abuse or dependence. There is a wealth of evidence that she has maintained the abuse or dependence post-service. All the psychiatrists who have seen Mrs Thompson have accepted that she suffers from alcoholism.
Dr Sime in his report of 8 June 1999 (A3 p4) described the onset and pattern of drinking during service and then added:
She was driving during the day and then would start drinking in the evening. She referred to drinking with a flight sergeant at his place and they would go through half a dozen bottles of beer between the two of them. She was living at home at the time and by the time she got home her parents would be in bed and wouldn't see her. She said that all this drinking was escape drinking in the setting of her stress she was under. She was drinking anything she could get including whisky and wine. The drinking was to go on after leaving the R.A.A.F. and into the present.
She refers to trying Alcoholics Anonymous but it didn't work. She referred to also being under the care of psychiatrist for three years in relation to her alcoholic problem. At one point the doctor started her off with A.A. and wanted her to go into Royal Park Hospital.
She said that in the present she attends the local R.S.L. three times a week and in the setting of her drinking this reaches a situation where the secretary approaches her and tells her to go home. She refers to drinking anything she can get hold of at the R.S.L. including beer and sometimes switching to wine. She also drinks spirits (whisky or brandy).
She appears to have had two drunk driving charges in 1958 and 1992. She referred to drinking seventeen or eighteen pots of beer and with a 0.227 alcohol reading. She stopped driving after this last episode three or four years ago.
Dr Cole wrote in his report of 27 December 1999 (A4 p3-4):
She did not drink before she joined the Air Force, as no-one in her family drank and she belonged to the Rechabite Lodge. She began to drink only after she had been in the Air Force for about a year. When she was persuaded to go into a hotel with a group and asked for a soft drink she was given a shandy. At first she didn't like it as it was bitter, but after a few drinks she started to feel better. She did not realise it was alcoholic but after that developed a taste for alcohol as she found it relaxed her. After the pilots and crews had been lost she found herself better able to cope with the losses. It was only after she started drinking that she was invited to parties. When she drank she felt great and drank everything she could get her hands on. She started wheeling and dealing in order to get alcohol. She still drank up to thirteen pots of light beer a day followed by a few stubbies when she came home. She did not keep count of how much she drank and switched to light beer only after she had been hauled over the carpet at the Club for being drunk. When she began to drink she rapidly developed a tolerance for alcohol. Often she would suffer from shakes and nausea and had to have a drink to control them. She still drank her way out of hangovers. Although she started off with good intentions it seemed to sneak up on her and she ended up drunk. She had tried to cut down without success. She had eleven slabs at home at present and made her own spirits. She had lost her licence twice for drink driving.
Dr Strauss wrote in his report of 5 May 1999 (R2 pp10-11)
"I believe that she has suffered from alcoholism as defined in the Statement of Principles.
She has consumed large amounts of alcohol for many years to achieve intoxication and I suspect that she has not coped well with any withdrawal attempts.
She has made unsuccessful efforts to cut down or control her alcohol use and I believe that her alcohol use has effected [sic] social and occupational activities in this woman's life.
She has also developed some physical symptoms associated with her alcohol abuse but her alcohol abuse has continued despite this.
In summary then I believe that she has suffered from alcoholism and a post traumatic stress disorder and I believe that these diagnoses satisfy the definition of the conditions as contained in the relevant Statements of Principles.
I believe that her service experience has significantly contributed to her conditions although other factors have to a lesser extent been also relevant as mentioned.
I believe that the applicant's conditions do satisfy the factors contained in the relevant Statements of Principle.
I believe that the applicant's conditions are 75% related to her service experience with the Royal Australian Airforce."
Mrs Thompson has been convicted of drink driving offences and she no longer drives because of her problems with alcohol. She now accepts her alcoholism, although in the past she attended AA for many years without success.
We find that Mrs Thompson suffers from psychoactive substance abuse or dependence and that it is a war-caused disease.
post traumatic stress disorder
The relevant SoP concerning PTSD is Instrument No. 16 of 1994, as amended by Instrument No. 225 of 1995. The definition of PTSD in paragraph 4 of the SoP is as follows:
"post-traumatic stress disorder" means a psychiatric condition meeting the following description (derived from DSM-IV):
(a)the person has been exposed to a traumatic event in which:
(i)the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others; and
(ii)the person's response involved intense fear, helplessness, or horror; and
(b)the traumatic event is persistently re-experienced in one or more of the following ways:
(i)recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions;
(ii)recurrent distressing dreams of the event;
(iii)acting or feeling as if the traumatic event were recurring (including a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated);
(iv)intense psychological distress at exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event;
(v)physiological reactivity on exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event; and
(c)persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three or more of the following:
(i)efforts to avoid thoughts, feelings, or conversations associated with the trauma;
(ii)efforts to avoid activities, places, or people that arouse recollections of the trauma;
(iii)inability to recall an important aspect of the trauma;
(iv)markedly diminished interest or participation in significant activities;
(v)feeling of detachment or estrangement from others;
(vi)restricted range of affect (eg, unable to have loving feelings);
(vii)sense of a foreshortened future (eg, does not expect to have a career, marriage, children, or a normal life span); and
(d)persistent symptoms of increased arousal (not present before the trauma), as indicated by two or more of the following:
(i)difficulty falling or staying asleep;
(ii)irritability or outbursts of anger;
(iii)difficulty concentrating;
(iv)hypervigilance;
(v)exaggerated startle response; and
(e)duration of the disturbance (indicated by the relevant symptoms set out in paragraphs (b), (c) and (d)) is more than one month; and
(f)the disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
There is little factual dispute about the fact that Mrs Thompson persistently re-experiences the traumatic or severely stressful event which we have found was constituted by her service as a driver at Sale Air Base, and in particular, by the deaths as a result of crashes of approximately 120 aircrew, many of whom were her friends. Nor is there significant dispute about Mrs Thompson satisfying the symptomatic criteria set out in paragraphs (b) (c) (d) (e) and (f) of the definition in the SoP. All the psychiatrists whose reports are before the Tribunal, and who obtained a history of the aircrashes at Sale, diagnosed her as suffering PTSD related to service. Dr Strauss in a later report of 6 October 1999 changed his opinion as to the cause of the PTSD, but he did not vary the diagnosis.
As to criterion (b) Mrs Thompson has consistently described having recurrent and intrusive recollections and images of the young men who lost their lives. As to criterion (c) her failure to mention the crashes to Dr Smith and Mr Dumbrell satisfies (i) as does her dependence on alcohol. She reports avoiding RSL marches and war films on television. She also described to the psychiatrists a range of feelings satisfying (iv), (v), (vi) and (vii). Mrs Thompson reported sleep problems since service and instability and outbursts of anger, (d) (i) and (ii). She has had those symptoms since service (e) and they have caused clinically significant impairment in social functioning.
The real issue concerning PTSD is whether Mrs Thompson experienced "a stressor" related to service, prior to the clinical onset of PTSD. The definition of "experiencing a stressor" is different from the definition of "severely stressful event" in the SoP relating to psychoactive substance abuse or dependence. The circumstances, which, in our opinion, satisfied the definition of "severely stressful event", may not satisfy the definition of "experiencing a stressor" in the PTSD SoP. That definition is as follows:
"experiencing a stressor" means the following (derived from DSM-IV):
(a)the person experienced, witnessed, or was confronted with an event that involved actual or threatened death or serious injury, or a threat to the person's, or other people's physical integrity; and
(b)the person's response to that event involved intense fear, helplessness or horror;
. . .
Each plane crash in which aircrew were killed or wounded while Mrs Thompson was at the Sale Air Base could be a possible stressor, but the issue is whether Mrs Thompson was "confronted with" any of those crashes. She clearly did not experience or witness the crashes.
We accept Mrs Thompson's evidence. We find that she suffered helplessness and horror as she learnt of the deaths of a number of the young aircrew who were known to her and some of whom she had driven to their planes prior to the fatal crash. Those events involved actual death and threats to the physical integrity of those aircrew. The question is whether Mrs Thompson "was confronted" with those events. The definitions of the word "confront" in the Shorter Oxford English Dictionary Clarendon Press Oxford 1983 are as follows:
1.To border upon, against – 1614.
2.Trans. To stand or meet facing; to face, esp. in hostility or defiance; to present a bold front to (lit. and fig.) 1568.
3.Trans. To bring together face to face with 1627.
4.To set face to face or side by side with for purposes of comparison, etc. 1613.

Those definitions seem to suggest that the meaning of the word "confront" involves a literal confrontation or being brought face to face with something. However the dictionary includes an example which demonstrates that the verb "to confront" can be used figuratively, and is not necessarily always used in a strictly literal sense:

4. The old order of things, when confronted with the new JOWETT.

While writing these reasons for decision the Tribunal became aware of a more recent Oxford Dictionary, The Australian Oxford Dictionary, Oxford University Press 1999. That contains a somewhat different definition of the word "confront" as follows:
1 a face in hostility or defiance. b face up to and deal with (a problem, difficulty, etc.). 2 (of a difficulty etc.) present itself to (countless obstacles confronted us). 3 (foll. by with) a bring (a person) face to face with (a circumstance), esp. by way of accusation (confronted them with the evidence). b set (a thing) face to face with (another) for comparison. 4 meet or stand facing. . . .
The Tribunal arranged for the District Registrar to send the relevant extract from The Australian Oxford Dictionary to the parties and to invite them to make submissions as to the applicability of that definition. We conclude that both the example in the Shorter Oxford English Dictionary and the definition in the Australian Oxford Dictionary indicate that a person may be confronted with a fact or a difficulty by being made aware of the fact, or difficulty and having to face up to or deal with it.

We have considered the decisions referred to in the respondent's solicitor's letter dated 18 July 2000 and the decisions cited of Re Slattery and Repatriation Commission (AAT 427, 16 June 1998 and Re Budworthand Repatriation Commission [2000] AATA 127. Neither decision is of much assistance in determining the meaning of "confronted". In Slattery, the Tribunal decided that the applicant had experienced witnessed or confronted death, and did not consider the position of an applicant who had not experienced or witnessed but only confronted death. Deputy President Forgie did say that "confronted" suggested "that he or she was faced with such an event". That observation seems to support the emphasis in The Australian Oxford Dictionary on "facing" in defining "confront". In Budworth, the Tribunal decided that the events experienced were not sufficiently traumatic to satisfy the SoP. The issue as to whether the events had been confronted did not arise. The particular facts in those matters are very different from those before us and do not assist us in deciding how the words in the SoP should be construed.
The respondent submits that the applicant was not confronted with an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others, as she did not come face to face with any such events. We accept this submission. As the dictionaries make clear there are many ways in which one may be confronted with or brought up against something, many of them abstract rather than concrete. However, when the word "confront" is used in the sense of being confronted with an event, we consider it does indicate that the person saw the event or the physical aftermath or consequences of the event.
We have found that Mrs Thompson's service at Sale Air Base was a severely stressful event. But we find it falls short of her being confronted with the events when planes crashed. We find that she neither experienced, witnessed nor was confronted with those events.
Mrs Thompson gave evidence of an occasion that involved serious injury to a member of aircrew, when she saw one man who had survived four crashes who "had no hair, no eyebrows, he was grey where the flames had burnt him, he was just vibrating and talking incoherently". The Tribunal finds this to have been a severely stressful incident, but we cannot find that Mrs Thompson confronted the event in which he sustained his severe injuries. The situation may well have been different if Mrs Thompson had been the ambulance driver required to pick up the injured aircrew.
We accept Mrs Thompson's evidence that the predominant feeling when she learnt of the deaths of aircrew was of horror. Dr Cole wrote (A4 p.4)
In my opinion, Mrs Thompson meets the requirements of the Statement of Principles for a post-traumatic stress disorder with the possible exception of 2(b) (A) [sic]. She did not apparently experience or witness an event or events that involved actual or threatened death or serious injury, but it could be argued that she was confronted with such events when she went to pick up pilots and crews only to learn that they had been killed or seriously injured. In view of her emotional attachment to them, this would be calculated to cause her considerable emotional distress and, according to her, did in fact do so. I do not think that she would have any difficulty in satisfying the remaining criteria and I cannot think of any other diagnosis that would better describe her emotional reaction.
However, we find that Mrs Thompson's experiences were not such as to satisfy criteria (a) (i) in the SoP. Accordingly we do not find that Mrs Thompson is suffering from PTSD, which is a war-caused condition.
It was a matter of concern to the Tribunal that although Professor McCarthy's report as to the number of aircraft crashes and related deaths (R5) was dated 2 October 1999, it was not sent to Dr Strauss before he wrote his reports of 6 October 1999 and 1 February 2000. Dr Strauss said that Professor McCarthy's report certainly made him aware of the number of people who died and "is proof that Mrs Thompson did go through a pretty profound experience while she was there, if indeed she was associated with a number of these deaths" (trans. p141). We would have considered his two later reports more helpful if they had been written with knowledge of the number of air crashes and deaths while Mrs Thompson was at Sale Air Base. It is also unfortunate that Mrs Thompson when asked by Dr Strauss about the car accident in which a pedestrian was killed, did not give him a full account of that accident.
throat stomach and gullet
Mrs Thompson in evidence and in the histories she has given to doctors has described problems with watery diarrhoea of varying degree most of the time. She reported having a problem with bowel accidents. She said the diarrhoea had started during service. There is a difficulty in diagnosing this condition. The Commission had before it a report from Dr Murphy dated 16 July 1997 (T21 p55) in which he described the gastroenterological conditions as follows:
"The sore dry throat in my opinion is caused by heavy cigarette smoking. There appear to be no oesophageal problems ……
Her anorexia and occasional vomiting are probably due to alcoholic gastritis ….
Her right lower abdominal pain and alternating diarrhoea and constipation are probably due to an irritable bowel syndrome."

Dr Murphy wrote that he could see no reason to relate those conditions to war-time service unless Mrs Thompson's heavy drinking and smoking were considered to be related to such service.

The Commission rejected the claim for irritable bowel syndrome as the SoP did not uphold the claim. There are only two factors specified in paragraph 5 of that SoP in respect of the onset, rather than the clinical worsening, of irritable bowel syndrome. They are:
(a)suffering a specified psychiatric condition within the six months immediately before the clinical onset of irritable bowel syndrome; or
(b)suffering an episode of severe diarrhoea within the six months immediately before the clinical onset of irritable bowel syndrome; or
In a later report of 5 March 1999 (R1) Dr Murphy changed his opinion. First he diagnosed gastro-oesophageal reflux disease. Secondly he wrote:
. . .
(b) Bowel condition. On the basis of the present history provided, I am obliged to withdraw my previous diagnosis of irritable bowel syndrome and replace it with one of alcoholic diarrhoea. The absence of abdominal pain and the profuse nature of the diarrhoea – in the absence of any other diagnostic information – necessitate this change. The condition does not meet the requirements for the diagnosis of irritable bowel syndrome in the relevant Statement of Principles.
Mr Dumbrell, who is a general endoscopic and laparoscopic surgeon, in his report dated 24 March 1998 (T33) stated that Mrs Thompson's abdominal symptoms were not really consistent with the diagnosis of irritable bowel syndrome. It was his opinion that her intermittent diarrhoea was due to her alcoholism and did not attract an impairment rating. He did not explain why no impairment rating was appropriate. The VRB did not feel it necessary to choose between the diagnoses of Dr Murphy and Mr Dumbrell. It explained that as it did not accept the alcohol consumption as war-caused, if the severe diarrhoea were due to excessive alcohol consumption, it would also not be accepted as a war-caused condition. If the diarrhoea were due to irritable bowel syndrome, the requirements of the relevant SoP were not met, and therefore once again the condition would not be war-caused.
When the matter came before the Tribunal, evidence was given by Mr Marshall and Dr Murphy. Mr Marshall has had a long experience as a senior gastroenterological surgeon, having been head of gastroenterology at Prince Henry's Hospital from 1980 until the hospital closed. He had written a report (A1) in which he said that Mrs Thompson did suffer gastro-oesophageal reflux but that was a symptom not a disease. He said that it was a symptom which could be attributable to excessive cigarette smoking. Secondly, he shared the view of Dr Murphy that Mrs Thompson did seem to suffer from irritable bowel syndrome, but he explained at length that in his opinion the factors specified in the SoP in relation to irritable bowel syndrome were not factors which caused the condition. He wrote:
. . .
It is indeed, as suggested in Instrument No 104 of 1996, associated with psychological upset, and in my view should be regarded as being a purely psychosomatic phenomenon. By definition if there is any physical cause such as colitis, or Crohn's disease, or diverticular disease, or carcinoma, it is by definition not irritable bowel syndrome. It does not follow as a physical consequence of an episode of severe diarrhoea (caused, for example by cholera or some other tropical disease). Instrument No 104 is therefore totally confused in its criteria, where it specifies this in 5b. The criteria constantly speak of "irritable bowel syndrome" as if it were a defined condition like appendicitis, and nothing could be further from the truth. To insist that there must be a specified psychiatric condition present six months before the onset of irritable bowel syndrome is to indicate a total misunderstanding of the whole process. The truth is that irritable bowel syndrome does not start abruptly in this sort of way. It is a series of symptoms of gradual onset associated with feelings of distension and nausea and irregular bowel habit for no obvious reason.
I would certainly agree that as stated in Section 3 it is more probable than not that irritable bowel syndrome can be "related to relevant service". But to make a determination about this onset, as in the case of Mrs Thompson, on the basis of the gobbledygook set out in Instrument No 104 can only result in a travesty of justice. If in fact irritable bowel syndrome were only ever diagnosed in our hospitals if the patient had had a recognised psychiatric condition within six months before the onset of symptoms, the diagnosis would never be made. This is not to say that irritable bowel syndrome is not psychiatrically caused, but merely to say that people who develop irritable bowel syndrome do indeed have a psychiatric upset, but it has almost never been recognised by anyone, including the usual medical attendant!
I understand very clearly that De Marchi & Associates must operate within the guidelines set out by the Statements of Principles released from time to time by the Veterans' Review Board. The fact remains, however, that these Statements are a collection of irrelevant stupidities and it is not possible to reach any logical conclusion with them as a basis.
As on past occasions, I must insist that if the Board is to make any rational, meaningful decision about cases such as this one involving Mrs Thompson, the Board simply must have it explained exactly what the realities of the situation are, and not proceed on the basis of fairytales concocted by those who simply do not understand the problems involved.
We suggest that a copy of these reasons should be referred to the Repatriation Medical Authority as it may be that they would like to review the SoPs in the light of the views expressed by Mr Marshall. However, this Tribunal is bound to consider the condition of irritable bowel syndrome in accordance with the relevant SoPs, rather than in accordance with Mr Marshall's opinion, however, expert he may be. Mr Marshall was prepared to diagnose Mrs Thompson as suffering from irritable bowel syndrome, but when he was told that Dr Murphy, in his report dated 5 March 1999, had withdrawn the diagnosis of irritable bowel syndrome and replaced it with one of alcoholic diarrhoea, Mr Marshall said that it is absolutely true that excessive drinking, particularly of spirits, can and does lead to symptoms of bloating and diarrhoea which are technically indistinguishable from irritable bowel syndrome.
The difficulty is that although Mr Marshall said that the two conditions of alcoholic diarrhoea and irritable bowel syndrome are indistinguishable (trans. p23), Dr Murphy does not share that view. In his opinion, in his second report dated 5 March 1999 (R1), he wrote (paragraph 2(b)) as set out in paragraph 60 of these reasons that he was obliged to withdraw the diagnosis of irritable bowel syndrome and replace it with alcoholic diarrhoea. There was evidence that Mrs Thompson had undergone endoscopy and colonoscopy. We arranged to obtain copies of the reports of those procedures to see if they would help in diagnosing the condition causing the diarrhoea. Unfortunately they did not do so.
We find on the basis of the opinion of Dr Murphy, with which Mr Marshall did not disagree, that Mrs Thompson's symptoms of diarrhoea are best described as "alcoholic diarrhoea", and that they result from her alcohol intake. In those circumstances, it is not necessary to consider further the SoP for irritable bowel syndrome. As we have found that psychoactive substance abuse or dependence is a war-caused condition, it would seem appropriate to assess the diarrhoea as part of that condition. The introduction to Guide to the Assessment of Rates of Pensions ("GARP"), "How to Use this Guide", at page 8, has the heading "Conditions and their sequelae." It provides:
Only the clinical features of an accepted condition may be taken into account in making an assessment. If the accepted condition causes some other distinct and diagnosable condition (sequela), the symptoms of the sequela cannot be taken into account when assessing the original accepted condition. Sequelae can only be assessed when they have themselves been separately determined to be war-caused or defence-caused.
As a general guide, a condition that is the subject of a Statement of Principles in force on 18 April 1998 should be taken as a separate disease entity. For the purposes of the preceding sentence, "Statement of Principles" has the meaning given to it on page 2 of this Guide.
As there was no SoP for alcoholic diarrhoea in force either at the time of the original decision 19 October 1997, or on 18 April 1998 (it is not clear from the introduction to GARP why that date is significant), or even as at the date of hearing, we consider it appropriate to assess the symptoms of alcoholic diarrhoea as a clinical feature of the psychoactive substance abuse or dependence.
gastro-oesophageal reflux disease
Both Mr Marshall and Dr Murphy agree that Mrs Thompson suffers from gastro-oesophageal reflux disease. Dr Murphy (R1) did not regard it as war-caused because he said it is due to a naturally recurring incompetence of the valve at the gastro-oesophageal junction sometimes associated with hiatus hernia and sometimes precipitated or aggravated by pregnancy or abdominal obesity. However Mr Murphy did say (at trans. p149):
Alcohol is a very powerful stimulus to acid production. On that basis, her heavy drinking would undoubtedly have increased the acid production and would have increased the amount of oesophagitis that would otherwise be present.
Is that temporary or long term?---Well, it would be temporary, provided the alcohol intake was temporary.

In this matter there is no evidence that Mrs Thompson's heavy alcohol intake was temporary. We find that it has been continuing since service.

The SoP concerning gastro-oesophageal reflux disease, Instrument No 122 of 1995, does recognise alcohol intake as a relevant factor in the onset of gastro-oesophageal reflux disease. It specifies ten factors which, if service-related, can allow it to be said that on the balance of probabilities gastro-oesophageal reflux disease is connected with circumstances of service. One of those, paragraph (j) is "smoking cigarettes or other tobacco products as an addiction before, and until the clinical onset of gastro-oesophageal reflux disease" another, paragraph (k), is "exhibiting psychoactive substance abuse or dependence involving alcohol before and involving the consumption of alcohol continuing at least until, the clinical onset of gastro-oesophageal reflux disease".
We have already found that Mrs Thompson suffers psychoactive substance abuse or dependence, and has done so since her service, and that the condition is war-caused. Her evidence is that the clinical onset of gastro-oesophageal reflux disease was during her Air Force days (trans. p58). Thus we find that gastro-oesophageal reflux disease is a war-caused disease. In those circumstances it is not necessary for us to make any findings concerning Mrs Thompson's smoking habit.
assessment
We have found the following conditions to be war caused:
psychoactive substance abuse;
alcoholic diarrhoea
gastro-oesophageal reflux disease

It is therefore necessary for an assessment to be made as to the rate of pension payable to Mrs Thompson in respect of those conditions.

Mr De Marchi in his Statement of Facts and Contentions dated 25 August 1999 made submissions as to assessment. The respondent's Statement of Facts and Contentions did not address that issue and Mr Lilley was not ready to make submissions as to assessment at the hearing. The Tribunal therefore gave him time to lodge a submission as to assessment.
When Mr Lilley lodged his submission as to assessment he submitted first that the issue of assessment should be remitted to the Commission under s 42D. We are reluctant to delay the finalisation of this claim any longer. The Tribunal is considering a claim lodged on 20 March 1997. The issue of assessment arises whenever there is an issue as to entitlement. It was clearly raised by Mr De Marchi in his Statement of Facts and Contentions which was lodged almost six months before the start of the substantive hearing on 3 February 2000. The Tribunal has before it Mrs Thompson's Lifestyle Questionnaire completed on 5 March 1999. The question of assessment is addressed in the reports of Dr Parkin, Mr Dumbrell, Dr Sime, Dr Murphy and Dr Strauss. We propose to proceed to assess the pension payable to Mrs Thompson as a consequence of our finding that the specified conditions are war-caused. She is already in receipt of pension at 40% of the general rate in respect of an accepted condition of acquired cataracts in both eyes (T28).
Mr De Marchi's submitted that if both PTSD and psychoactive substance abuse or dependence were accepted separate ratings should be given for the two conditions on Chapter 4 of GARP. The Tribunal considered that issue in Re Clarke and Repatriation Commission [2000] AATA 545 at paragraphs 38–41 where it said:
38.      It is necessary for the Tribunal to consider as a preliminary matter the submission of Mr Moore that a separate rating should be given on Chapter IV for emotional and behavioural impairment in respect of the now accepted condition of anxiety disorder not otherwise specified, in addition to that for psychoactive substance abuse or dependence. The Tribunal pointed out to Mr Moore that the introduction to Chapter IV states:
Only one final rating is to be determined using this Chapter for any psychiatric condition or combination of psychiatric conditions.
39.      Mr Moore submitted that notwithstanding that direction, it was appropriate to calculate two separate ratings on Chapter IV, one for psychoactive substance abuse or dependence and one for anxiety disorder not otherwise specified. He submitted that psychoactive substance abuse or dependence should not be characterised as a psychiatric condition, and thus that the passage quoted in the preceding paragraph, from the Introduction to Chapter 4 of GARP did not preclude two ratings using Chapter 4. We reject that submission. It is clear that the intention of GARP is that only one rating per Table is to be adopted. That rating is to take into account all the accepted conditions which create an impairment of the sort covered by that Table or Chapter. That is explained in the How to Use this Guide at GARP p6. It states:
If two or more conditions contribute to the same functional loss, a single rating only is to be given for that functional loss.
40.      Only one final rating is to be determined on Chapter 4 for emotional and behavioural impairment from any war-caused injury or disease. The appropriate final rating on Chapter 4 of GARP must take into account the effects not only of psychoactive substance abuse or dependence, but also any emotional or behavioural impairment of Anxiety Disorder not otherwise specified.
41.      We have given our reasons for that conclusion. In addition we consider it appropriate to note, in respect of Mr Moore's submission that psychoactive substance abuse or dependence is not a psychiatric disease, that one chapter of DSM IV is devoted to "Substance-Related Disorders". That would seem to suggest that psychoactive substance abuse or dependence is a psychiatric condition.

As Mr Lilley pointed out in his submission, the notes to Chapter 4, at p90 of GARP, make it clear that substance abuse is to be assessed using Chapter 4 of GARP. We accept his submission that only one rating would be given on Chapter 4 for both PTSD and psychoactive substance abuse, had we found them both to be war-caused. However as we have rejected the claim for PTSD the only assessment on Chapter 4 is in respect of psychoactive substance abuse. On the evidence we find that condition was the major cause of emotional and behavioural impairment.
emotional and behavioural impairment
Chapter 4 requires that ratings be given on Tables 4.1 to 4.8. We find that the appropriate ratings are as follows:
4.1 subjective distress
TENVery frequent symptoms causing moderate distress. The veteran will often be unable to distract himself or herself from the distress.

This was the rating selected by Dr Parkin. He noted "regular problems with sleep, drinks each day significantly, ongoing major problems, nightmares on occasions" (T32 p92). Dr Strauss gave a rating of TEN noting "the veteran suffers from ongoing concern and distress and uses alcohol daily as a way of dealing with this distress". We consider that the rating selected by Dr Parkin and Dr Strauss bests meets the description of "Subjective Distress" experienced by Mrs Thompson.

4.2 manifest distress
SIX Distress is apparent, and/or the veteran's pre-occupation with the symptoms is noticeable to astute observers or persons familiar with the veteran.

Dr Parkin noted that Mrs Thompson's distress is quite apparent and her preoccupation with her symptoms is evident, he noted (T32 p93)

Children know. Lady friend who knows. People in public pick it up.

Dr Strauss chose a rating of SIX with the comment "It was apparent at interview that the veteran does experience some distress even though to a certain extent she tries to hide upset". We find that the appropriate rating is SIX.

4.3 functional effects
THREE Moderate interference with functions in many everyday situations.

Dr Parkin noted "marked interference with function in everyday situations" which would be equivalent to a rating of FIVE on the current Table. Dr Strauss gave a rating of THREE for "moderate interference with functions in many everyday situations". The comment made by Dr Strauss was "The veteran has gradually lost interest in some daily activities and is less concerned about personal hygiene and maintenance in the home. She isolates herself and is not particularly interested in looking after herself in respect to diet." Those matters relate to the alcohol abuse. We find that there is moderate interference with functions in many everyday situations and accordingly a rating of THREE is appropriate.

4.4 occupation
FIVEAn employed veteran will have major difficulties at work, which may be manifested by job modification or restriction of career opportunities. The disorder may contribute to the loss of a job.

Dr Parkin noted "Had to leave work because of hypertension related to drinking. Was successful but worked with hangovers and retired at 51. Potential was for so much more". Dr Strauss gave a rating of FIVE saying "I believe that to a certain extent she gave up work some years ago because of her psychiatric problems related to her service experience. I believe that she was unable to keep working and she has not worked for 20 years". The rating FIVE is appropriate. Mrs Thompson's career opportunities ceased early. We find that her psychiatric problems and alcohol abuse played a part in her early retirement.

4.5 domestic situation
SIXFamily functioning is deteriorating, and estrangement or divorce are a likely consequence.
Dr Parkin noted "Divorced because of drinking". Dr Strauss gave a rating of SIX noting "She underwent a divorce which was significantly contributed to by her psychiatric problems as well as her husband's problems and she has remained estranged ever since". We find a rating of SIX is appropriate.
4.6 social interaction
SIX General social withdrawal.

Dr Parkin noted "Goes out to RSL every Monday night - several nights or days but normally sits on her own to avoid the war conversations. Also a lady friend who visits". Dr Sime gave a NIL rating for social interaction saying "PTSD not applicable here. Dysfunction through . . . alcoholism". Dr Strauss commented "She is relatively isolated and has few friends and sees her sons only occasionally". He gave a rating of SIX which is appropriate for general social withdrawal. We agree with that rating.

We reject the submission of Mr Lilley that the fact that Mrs Thompson does attend the RSL indicates socialisation rather than withdrawal. The clear picture she gave in her evidence, and to the psychiatrists, was of sitting on her own. Also she said that on occasions she has been asked to leave the RSL where she is seen as somewhat of a problem because of her drinking.
4.7 leisure activities
FIVE Loss of interest in most recreational pursuits.

Dr Parkin noted that "Leisure is drinking, RSL, Garden. That's it". Dr Sime gave a rating of NIL for leisure activities saying "Affected by drink rather than PTSD". But of course we are rating for drinking and not PTSD. Dr Strauss gave a rating of THREE with the comment "She has few leisure activities although she still reads a little but has given up gardening partly because of her physical problems". It seems to us that a rating of FIVE is appropriate for loss of interest in most recreational pursuits.

4.8 current therapy
THREEPsychiatric treatment, at least in the form of medication or psychotherapy, has been used (or deemed necessary), and/or periods of regular supportive therapy at an outpatient level or similar.

Dr Parkin noted, "Has seen psychiatrists in the past. On one occasion for 3 years. No hospitalisations. Has had anti-depressants. Now takes sleeping tablets – Temezepan. Last saw a psychiatrist 64 & 67. Then LMOs [local medical officers] took over". Dr Sime gave a rating of TWO with the comment "Psychiatric treatment would be appropriate". Dr Strauss gave a rating of THREE with the note "She has had psychiatric treatment and some supportive help through Alcoholics Anonymous but it did not help her significantly". We find the rating THREE to be appropriate.
combining the ratings for psychiatric impairment

GARP, at page 90, explains that to calculate the impairment rating for psychiatric conditions it is necessary to add together the following impairment ratings:
Table 4.1 – Subjective Distress    Rating 10
           4.2 – Manifest Distress      Rating 6
And the three highest ratings from Tables 4.3 – 4.8
           4.5 – Domestic Situation    Rating 6
           4.6 – Social Interaction      Rating 6
           4.4 – Occupation, or           )         4.7 – Leisure Activities)      Rating 5
           TOTAL         33
We find that the appropriate impairment rating on Chapter 4 for emotional and behavioural effects of psychoactive substance abuse or dependence is 33 impairment points. To that must be added impairment points for alcoholic diarrhoea and gastro-oesophageal reflux disease. We accept the submission of the respondent that the appropriate Table on which to rate the faecal incontinence is Table 6.1.3. Mrs Thompson gave no evidence of medication, such as to attract a rating on Table 6.1.8. We also accept the rating of 5 impairment points on Table 6.1.4 as suggested by Dr Murphy for the gastro-oesophageal reflux disease. In addition there is the previously assessed condition of acquired cataracts in both eyes, for which an impairment rating of 20 was accepted by the Repatriation Commission (T28 p71).
Combining all the impairment ratings on Table 23.1, the final combined impairment rating is 50 impairment points. By reference to the Tables contained in Chapter 23, 50 impairment points converts to a pension of 90% of the General Rate taking the higher of the ratings within the shaded area. We see no exceptional circumstances such as to suggest that a rating outside the shaded area should be chosen. We agree with Mr Lilley that there is no justification for a finding that Mrs Thompson is entitled to the extreme disablement adjustment.
The decision of the Veterans' Review Board made 30 September 1998 will be set aside.   In substitution the decision of the Repatriation Commission made 17 October 1997 will be varied to provide:
1.Psychoactive substance abuse or dependence, alcoholic diarrhoea, gastro-oesophageal reflux disease and acquired cataracts are war-caused diseases within the meaning of that term in s 9 of the Veterans' Entitlements Act 1986 ("the Act") with effect from 24 December 1996.
2.Mrs Thompson is entitled to pension at 90% of the General Rate from 24 December 1996.
I certify that the 86 preceding paragraphs are a true copy of the reasons for the decision herein of Mrs Joan Dwyer, Senior Member, Mr I Campbell, Member and Dr P Fricker, Member.
Signed:         Anne O'Rourke
  Associate
Date/s of Hearing  3 February and 9 May 2000
Date of Decision  2 August 2000
Counsel for the Applicant        Nil
Solicitor for the Applicant         Mr D De Marchi
Counsel for the Respondent    Nil
Solicitor for the Respondent    Mr B Lilley