426 The third psychiatrist relied upon by the Plaintiff was Dr Phillips, who first assessed him at the request of his solicitors on 30 June 2005.
427 In a report dated 3 August 2005, he reviewed in some detail the history he relied upon, which immediately creates a difficulty in that much of the history, particularly that concerning his claim to have been overworked; the alleged unprofessional management techniques of Dr Darling; and some aspects of the leadership course, were not proved and, indeed, in my opinion, established to be false. However, upon the history he took, Dr Phillips said:
"It is rather difficult, on the information to hand, to reach a categorical view regarding Dr MacKinnon's diagnosis. At first cut, he appears to have suffered a schizophrenic illness. However there are a number of matters which lead me to question that diagnosis. He is not within the usual age group for the development of schizophrenia, he has experienced marked mood swings throughout his period of illness, he has retained his warmth and his capacity for empathy and his insight is intact. He has required treatment not generally essential in the management of schizophrenia (antidepressant agents, ECT) in order to make improvement.
More probably than not Dr MacKinnon has a schizoaffective disorder DSM-IV-TR 295.70, noting that in addition to frank psychotic symptoms the plaintiff has had prominent mood symptoms (depression) and his mood symptoms have been prominent throughout the course of his illness. Schizoaffective disorder generally has a better prognosis than schizophrenia, but I acknowledge that the disorder can prove very difficult to treat.
Dr MacKinnon will understandably require ongoing assertive therapy, as has been chosen by Dr Klug. He almost certainly will require both supportive psychotherapy (preferably one consultation every two weeks indefinitely) and medication with a combination of antipsychotic and antidepressant agents. He may at various times in the future require intermittent in-hospital care if his symptoms cannot be controlled adequately on an outpatient basis. Overall the Plaintiff has a guarded prognosis.
Putting all information together, Dr MacKinnon decompensated psychologically in late 1996 as a direct consequence of the stress which he experienced during the leadership course organized by BHP. He may have been predisposed to psychological decompensation at that time as a consequence of being medicated previously with Duromine, but this cannot be proven. He had developed a complicated and rather treatment refractory schizoaffective disorder. Whilst coping with his family life, the plaintiff has not been able to return to his professional life. I do not foresee him being able to take on professional duties in the immediate future."
428 In a report dated 12 April 2006, Dr Phillips reviewed a report obtained from psychiatrist, Dr Yvonne Skinner, which is not in evidence. Towards the conclusion of his report, Dr Phillips said:
"The issue of Dr MacKinnon's diagnosis remains problematic. Specifically:
* There should be no doubt that the Plaintiff developed psychotic symptoms during the period when he attended the BHP leadership course, with worsening of his symptoms at the time of his return to Sydney and thereafter.
* There should be no doubt that the Plaintiff has continued to suffer from a psychotic disorder of fluctuating type since then. He has required at various times in-hospital treatment and has a need for ongoing psychotropic medication.
* The specific diagnostic entity within the psychotic spectrum of illness remains uncertain.
* Dr Skinner maintains that the Plaintiff has a schizophrenic illness. I advised in my report of 3 August 2005 that it is more probable that the Plaintiff has a schizo-effective disorder, noting particularly his tendency to have prominent mood symptoms in addition to primary psychotic symptoms."
429 A report by Dr Phillips dated 27 April 2006 contained these paragraphs:
"Given that Dr Klug has had far more contact with Dr MacKinnon in his role of treating psychiatrist than colleagues who examined the plaintiff for medico-legal reasons, substantial weight needs to be given to Dr Klug's opinion that the plaintiff (his patient) has primarily an ongoing affective disorder with psychotic features."
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Despite knowledge that there are at least three reliable, valid and statistically appropriate prospective clinical studies linking life stress with the onset of psychosis, it is not possible to state categorically that absent life stressors, Dr MacKinnon would have been spared his psychological decompensation taking the form initially of a brief psychotic disorder and then a more substantive psychological disorder (either a schizophrenic disorder or a severe affective disorder with psychotic features). However, on the balance of probabilities, and taking into consideration all information now available to me, Dr MacKinnon would not have developed his escalating psychological symptoms during and following the leadership course in the absence of particular life stressors. To put it another way, the above mentioned stressors were the trigger for the plaintiff's psychological decompensation at that particular moment in time.
I cannot state that Dr MacKinnon was going to experience psychological decompensation during and following the leadership course, or that his decompensation was going to be less severe and less chronic, in the absence of the above mentioned stressors. However, it is probable, but unprovable, that absent those stressors, he would have coped with the leadership course or would have merely developed less significant non-psychotic symptoms during the course (e.g. the development of an adjustment disorder with anxiety and/or depressed mood, noting particularly that he had previously developed a 'reactive depression' at the time when his wife was diagnosed to have breast cancer)."
430 On 6 September 2006, while the trial was in progress, Dr Phillips provided a fourth report. In its production, he had regard to a schedule which he had requested, but which was apparently prepared by the Plaintiff's counsel. The schedule purported to comply with the requirements of Dr Philips.
"Specifically, I indicated that it was important, as far as possible, to quantify relevant information in Dr MacKinnon's matter. With this in mind, I advised that clinical information might best be divided into symptoms referrable to a mood disorder, and symptoms more suggestive of a psychotic disorder. Specifically, I advised five categories: primary depressive symptoms (incorrectly labelled Mood in the document), primary anxiety symptoms, mood congruent psychotic symptoms, positive and negative symptoms more suggestive of schizophrenia."
431 The report contains these passages:
"Dr McKinnon was undoubtedly suffering an acute psychotic disorder of some type at the time of admission to the Evesham Clinic in October 1996. The plaintiff had broad-ranging symptoms at the time which could encompass an acute psychotic disorder, a mood disorder with psychotic symptoms, or an organic psychosis. Symptoms of importance included visual hallucinations, tactile hallucinations, ideas of reference, posturing, pressure of speech and fears of darkness.
The plaintiff's symptoms changed to a degree in the days following his admission, with significantly greater mood related symptoms as time went by (particularly anhedonia, anxiety, panic symptoms).
The issue of the large shadowy figure into which Dr MacKinnon retained insight is interesting but has little diagnostic value.
The plaintiff was reported as not having delusions or hallucinations by 18 October 1996, but he was thought to have pseudo-visual hallucinations (with insight) on 19 October 1996.
Symptoms thereafter are rather mixed but mainly suggestive of a depression and/or anxiety spectrum disorder.
However, Dr MacKinnon had a further mixed group of probable psychotic symptoms on 25 October 2006 (sic) during a subsequent period of in-hospital treatment, but these did not continue.
The plaintiff's symptoms were predominantly in the depression and/or anxiety spectrum at least from 14 October 1996, but with possible paranoid interpretation of work-related matters on 22 December 1996.
Particular note should be taken of an entry made by Dr Klug on 24 December 1996 where he changed Dr MacKinnon's diagnosis from reactive depression to psychotic depression, and an entry by Dr Lyndon on 27 December 1996 where he advised inter alia that the plaintiff exhibited hopelessness, despair, tearfulness, suicidal thoughts, loss of appetite, early morning waking with diurnal mood variation and panic symptoms. He found no evidence of psychotic phenomenology at the time.
There was a single file entry on 23 August 1992 (sic 1997) in which Dr MacKinnon reported auditory hallucinations (external to his head). Reference is made on 25 August 1997 to the plaintiff fearing a shadow and to so-called pseudo-hallucinations on that day, and additionally to an hallucination (type unspecified) on 31 August 1997.
There is no useful evidence beyond late August 1997 to suggest Dr MacKinnon had any diagnosis beyond the depression and/or anxiety spectrum.
However there is a file entry on 3 October 2000 that BHP was poisoning his food, this probably being a psychotic symptom.
The pro forma admission document completed by Dr Short on 11 January 2001 (probably 2002) advises that Dr MacKinnon had a blank facies and that he had a flat humourless affect. The psychiatrist considered the plaintiff to have chronic schizophrenia. The plaintiff thought himself to be the "scum of the earth" at the time.
Dr MacKinnon reported believing there was a GPS tracking device in his stomach on 18 August 2003, but he retained insight at the time into the abnormal nature of his belief."
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Dr Klug described Dr MacKinnon on 19 April 2000 as suffering from depersonalisation and derealisation, and to have paranoid thoughts by 16 April 2000. The plaintiff experienced increasing depressive thoughts by 16 August 2000 (particularly guilt) and 27 October 2000 being a burden to others) and again to have depressive thoughts (principally denigration) on 15 June 2001 and severe depressive symptoms on 26 June 2001.
The psychiatrist advised that there had been a deterioration in Dr MacKinnon's condition on 19 October 2001, particularly that the plaintiff had further paranoid experiences and possibly ideas of reference, and some panic symptoms on 12 December 2001 and again paranoid symptoms on 1 February 2002. The plaintiff again experienced derealisation during May 2002 (exact date unrecorded) and increased anxiety on 27 June 2002 and derealisation on 28 august 2002.
Dr Klug noted Dr MacKinnon to have probable paranoid symptoms on 24 June 2003, and broad-based anxiety on 30 October 2003, and derealisation on 5 February 2004. the plaintiff was identified as having an unusual experience if not an hallucination (the smell of burning flesh) on 26 February 2004, chronic anxiety symptoms on 22 April 2004, 6 May 2004 and 20 May 2004. The plaintiff developed suicidal ideas following a medico-legal interview on 12 December 2004. He was recorded as being depressed on 24 February 2005 but not suicidal, and to be remaining anxious on 14 July 2005 and to have a variable mood state on 1 September 2005, and to be chronically anxious on 13 October 2005 and 5 November 2005.
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I am in broad agreement with notations contained within the schedule. It will become obvious on review of the schedule and cross-reference to the file entries that by far the greater number of entries will support Dr MacKinnon suffering from a depression and/or anxiety spectrum disorder, undoubtedly complicated at times by psychotic phenomena (generally on the basis of self-report).
Dr Klug's clinical notes should be accorded particular diagnostic weight, given that he is Dr MacKinnon's treating psychiatrist.
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There should be no doubt regarding Dr MacKinnon experiencing episodic psychotic symptoms. Psychotic symptoms always occurred in the context of ongoing depression and anxiety spectrum symptoms and are far more probably related to a worsening in the plaintiff's background mood disorder rather than representing other forms of psychotic disturbance (including schizophrenia).
Dr MacKinnon had mentioned on a number of occasions a strange experience perhaps best described as a "black person". On my review, the plaintiff appears to be using the words in metaphor to refer to deeply seated uncomfortable depressive thoughts, which are difficult to describe. I doubt that this experience represents a hallucination.
Whilst I did not choose to record Dr Klug's attempts to medicate Dr MacKinnon, my colleague's clinical notes confirm that at various times the plaintiff had been medicated with anti-depressant, mood stabilising, anti-psychotic and benzodiazepine agents but without particular therapeutic success. More likely than not the plaintiff has a medication-resistant psychological disorder, this of course not being uncommon.
Dr MacKinnon's psychotic symptoms (as recorded) are hardly typical of schizophrenia. They include visual and tactile hallucinations (more suggestive of an organic disorder, for which there is no other firm evidence), or so-called pseudo-hallucinations (more typically associated with histrionic symptomatology). I refer you particularly to the entry relating to hundreds of spiders.
Additionally, given the volume of the material, there are relatively few file entries which suggest delusional thinking. Perhaps the most striking is a comment by the plaintiff that he had a GPS tracking device located within his abdomen. However, the plaintiff retained insight into the bizarre nature of his thought, reducing significantly the likelihood that the symptom was based within a schizophrenic disorder.
It is critical to understand that psychotic symptoms are by no means restricted to schizophrenia. Psychotic symptoms reflect a person experiencing a break from reality, this generally being a marker for the magnitude/seriousness of the psychiatric disorder suffered by the person, rather than indicating a particular diagnosis.
On my evaluation, virtually every psychotic symptom recorded in the clinical file is consistent with Dr MacKinnon having a severe mood disorder.
Additionally there are comparatively few entries in the clinical file to suggest Dr MacKinnon was experiencing so-called negative symptoms of schizophrenia. Whilst Dr Short put some emphasis on what he considered to be negative symptoms, I believe the symptoms mentioned by him will equally or better be explained on the basis of a depressive disorder.
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The making of a psychiatric diagnosis is often an iterative process. This is the case with Dr MacKinnon. As mentioned in my previous report, I have altered my diagnosis from a schizoaffective disorder to a major depressive disorder, on the basis of the additional information now available to me. My alteration of diagnosis is entirely in keeping with analysis of the material in its totality and best medical practice.
I have been forced to discard the diagnosis of schizoaffective disorder because, on my analysis of Dr MacKinnon's clinical notes, criterion B for this diagnosis cannot be met, specifically noting that the criterion determines that the plaintiff must have "delusions or hallucinations for at least two weeks in the absence of prominent mood symptoms". Criterion A probably can be met and criteria B and C are met.
On the other hand, Dr MacKinnon clearly meets criteria for a major depressive disorder including experiencing a persistent anhedonic mood state, diminished interest and pleasure from the usual activities of life, sleep disturbance, significant psychomotor changes, intermittent fatigue, feelings of worthlessness, cognitive perturbation, nihilistic thoughts and noting particularly that his symptoms have caused distress and impairment in social, occupational and other significant domains of his life.
The diagnosis of schizophrenia has to be ruled out, noting in particular that criterion D for the disorder cannot be met as major depressive symptoms have occurred concurrently with other active-phase symptoms of the disorder. Specifically criterion D advises that "no major depressive, manic or mixed episodes (of illness) have occurred concurrently with the active phase symptoms (of schizophrenia)" and "if mood episodes have occurred during action -phase symptoms, their total duration has been brief relative to the duration of the active and residual periods". Put simply, mood symptoms rather than psychotic symptoms have been dominant in the case of the plaintiff."
432 As long ago as 1998, BHP arranged for Dr Milton to assess the Plaintiff. He wrote a long report to Mr Keyte of BHP on 20 September 1998, which included these paragraphs:
"Dr MacKinnon then joined the Illawarra Occupational Health Service, a private occupational health practice, and in mid-1995 joined the BHP occupational health service. Dr MacKinnon said his employment with BHP represented an innovation for the company in that he was to be employed treating patients, whereas doctors employed by BHP previously did nothing more than assess work injuries and refer patients to general practitioners.
He said the situation was not easy. He described the atmosphere in Wollongong as being a male-dominated culture and agreed it was polarised in regard to unions versus management. BHP was a self-insurer for workers' compensation and his office was next to the workers' compensation section, which he said placed him in a difficult situation because workers, already suspicious of him, thought he was automatically allied with management, and his proximity to the workers' compensation section increased these suspicions.
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Although the situation was demanding he did not feel it troubled him for the initial time he was there. The first six to eight months were largely uneventful apart from issues mentioned.
Dr MacKinnon felt bothered by Dr Darling. He said when Dr Darling was about his pulse went faster than at other times. About this time Dr MacKinnon was taking a stimulant, Duromine, for weight control and palpitations and tachycardia are side effects of that drug, suggesting it at least contributed to that symptom.
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On occasion Dr MacKinnon challenged Dr Darling but felt that doing so damaged Dr Darling and he should not have done it because Dr Darling responded angrily, which proved to Dr MacKinnon how fragile that other really was. (It is difficult to separate truth from reality in this regard - it is possible Dr MacKinnon was himself in a fragile emotional state and in consequence perceived his colleague in that light too).
Dr MacKinnon's patient numbers built up. He was successful in getting workers to trust him and many attended, and at one stage he was seeing between 30 to 40 patients a day. Your letter of referral stated that the plan was for the industrial medical officer to see about as many patients daily as general practitioners do. Dr MacKinnon said, however, that although some cases were simple, some were complex and he was also asked to write reports about many patients and found that demanding.
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Dr MacKinnon became concerned about his work load from about March 1996. He said Lisa Delaney sometimes commented to him about how much work he was doing. He said he had a couple of two-hour meetings with Dr Darling, Lisa Delaney, Di Ford and the ambulance officers in order to work out some way of reducing his work load. These meetings were not always harmonious and Dr MacKinnon felt that Dr Darling did not handle them properly. He considered not much was achieved by them. I note at page 2.2 in your letter of referral that the health and rehabilitation department was in the process of examining Dr MacKinnon's work load not long before he participated in the leadership course, but that Dr MacKinnon was reluctant to relinquish control of his work duties. This suggests Dr MacKinnon made a rod for his own back, at least to a degree.
Dr MacKinnon thought he began to develop problems from about March 1996. However, he dismissed certain symptoms as being purely physical in origin, although later he considered they were a reflection of his upset emotional state. He sometimes suffered a pain in his throat, and his hands and feet were cold.
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In addition to his cold hands and feet, he suffered urinary frequency. It is probable both these effects were from Duromine, the first by peripheral vasoconstriction, and the second by Duromine making him anxious and aroused. Further, he was said to have talked faster than normal, which could also have been a side effect of the arousal caused by Duromine. He considered he was under pressure, and said that others commented about it, e.g. a general practitioner who observed Dr MacKinnon do a presentation. He was not sleeping too well, another likely side effect of Duromine. He was, however, getting on well with his wife and she was supportive to him, and he maintained relationships with a small group of friends.
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Further he began to suffer what he described as tension headaches from about March 1996. (I note that headache is listed as a side effect of Duromine, although his account indicated he was probably not taking it at that time). He suffered low back pain and had a CT scan of his spine, but this showed no abnormality."
433 In an even longer and more detailed report dated 20 April 2000 to BHP's solicitors, Dr Milton reviewed and updated the history he had previously taken. He also extensively analysed the medical and hospital notes and records made available to him, including those of Dr Klug and Evesham Hospital. His report included these paragraphs:
"I questioned him specifically about psychotic phenomena, explaining the reason for these questions. He denied experiencing hallucinations and ideas of reference. He said he sometimes gets a feeling that people are talking about him but this is not a belief, i.e. a delusion. He said Dr Crino is helping him work on that tendency. He does not have a feeling or belief that the human race is invaded by aliens, or that thoughts are being inserted into his mind or that his thoughts are being broadcast to others. He does not consider people are conspiring against him. He said he is not psychotic and the reason he takes the antipsychotic chlorpromazine is because of his depression.
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(Dr MacKinnon has obsessional tendencies. A medical practitioner with such tendencies often has trouble separating important from unimportant issues and tends to take a long time over consultations. He is not as efficient as a person without those qualities. It is possible that something of this nature applied, and when Dr Darling brought it to his attention Dr MacKinnon was inflexible and this caused conflict. Obsessional people tend to be inflexible and do not like negotiating compromise.)
Dr MacKinnon did not present too badly on this occasion. He showed some spontaneity, e.g. when he was telling me about the skin cancer clinic in which he worked briefly, I mentioned that sometimes I was sent patients with skin cancer, general practitioners mistaking me for Professor Milton, whose field that is. Dr MacKinnon gave a spontaneous and normal grin at that.
As noted, he often banged his foot on the floor, saying this gave relief of anxiety. As the interview progressed, however, the foot-banging became somewhat less. When asked about certain topics the foot-banging stopped altogether, e.g. when I asked him about marital relations and when I went through the list of items supporting his claim for compensation. He is thus capable of being distracted from his anxiety by topics that interest him.
Dr MacKinnon was pleasant and cooperative, was wearing glasses and had a moustache. He seemed generally anxious and had a limited range of affect. There was no thought disorder or other obvious indications of psychosis.
I think it probable that Dr MacKinnon had emotional difficulties for a considerable time but used his good intelligence to cope with them. These pre-existing problems probably resulted in him having two periods, each of six months, off work, although the first was stated to have been associated with a severe viral infection, and the second with the shock of learning his wife had cancer. Nonetheless, it is unusual for such long periods of total incapacity to follow stresses of this kind in an otherwise normal person, and it is unusual for one person to have two periods of such incapacity from different causes. The most probable explanation is that there were serious pre-existing difficulties
Dr MacKinnon appears to have had a particular problem dealing with people in authority. There was mention from time to time of such childhood difficulties and of him trying to cope by putting his feelings aside. One note referred to him trying to make himself "a stone" so he would not have feelings. There was reference to him regarding pain in an unusual fashion, as something to be desired. Dr Klug described him consciously starving himself when he was a child and also referred to him having lost a good deal of weight at work by intentional dieting prior to the training program. (This could also be consistent with using an appetite suppressant, as described in my first report.) The material referred to him having developed an unusually strong interest in non-verbal communication and as having read a large number of publications (30 books) in that field in the months before the course.
The training course, in my view, precipitated a psychotic episode, which Dr Klug appropriately referred to as a "schizophreniform psychosis" (although Dr Klug later diagnosed schizophrenia when applying for medication). As noted, psychosis of this kind were sometimes observed following encounter groups but usually responded quickly to antipsychotic drugs, hospitalisation and support. Appropriate treatment of this kind was applied by Dr Klug during Dr MacKinnon's first admission.
Although he was floridly psychotic when first admitted, as is usually the case in such illnesses, the psychotic symptoms responded well to medication and after a time disappeared altogether, except for an occasional recurrence when he was under particular difficulty. In recent times there was no hint of him showing psychotic phenomena, with one exception to which I shall refer later. Careful questioning about delusions and hallucinations revealed negative results when I assessed him, and Dr Klug's detailed observations over many months were consistent with the disappearance of psychotic symptoms.
I suggest that significant problems, unrelated to occupation, were already in existence before the training program and these made it difficult for Dr MacKinnon to function efficiently at work. I think it probable these included obsessional tendencies (although there is no clear evidence of these); but in any event, his efficiency at work was not high, and when he was replaced by a locum the latter appears to have achieved better results in less time. One explanation is that Dr MacKinnon lacked confidence or was troubled by obsessional habits or by a mild and slowly developing schizophrenic illness, and in consequence took a long time to make decisions and, in the event, was ineffective in getting people back to work, though perhaps being critical of the methods of others who had more success.
The acute psychosis precipitated by the training group settled, and, as sometimes happens, was followed by severe depression. This too, responded to appropriate treatment by Dr Klug, in this instance, electroconvulsive therapy.
I noted above that Dr MacKinnon showed no residual psychosis, with one exception. I refer to the very poor abstract thinking ability demonstrate in his two interview with me. This raises the possibility that Dr MacKinnon has for some time been gradually developing a schizophrenic illness but was able to cope with it because of his good intelligence.
The poor abstract thinking ability demonstrated by him at my interviews is suggestive of schizophrenia rather than a "schizophreniform", or temporary, psychosis evoked by the training course. I would not expect the effects of the course to have a permanent influence on Dr MacKinnon's abstract thinking ability, that deficit being better explained as a part of a slowly developing mild schizophrenic illness. That is consistent with the training group evoking a very florid psychosis. Dr MacKinnon had already shown some eccentricities, e.g. starving himself as a child, trying to act like a stone and having no feelings, lacking colour vision for many years prior to the training course, and for fifteen years prior to the training course having no sense of smell. These phenomena might in fact have been more than eccentricities - they could have been indicators of a gradually developing schizophrenic illness.
434 Dr Milton next reviewed the Plaintiff in September 2003. In his report dated 2 September 2003, he expressed this opinion:
"Dr Angus MacKinnon shows increasingly the typical features of schizophrenia as it manifests in an intelligent patient with insight. He also shows the unfortunate decline in personality (oddity and blunting), which accompanies that illness. He still requires large quantities of antidepressant and antipsychotic medication, despite my earlier hopes that he might have been able to reduce this medication in due course.
In my opinion, he will not be able to return to work as a medical practitioner, and I doubt that he will be capable of any other occupation because of his continuing severe mental symptoms. Resolution of litigation will be helpful, but he is likely to continue to go downhill as time passes. He denies an intention to suicide; but persons suffering from schizophrenia have a significantly higher rate of suicide than others, and in my experience this applies particularly to the patient of good intelligence and insight who perceives the gradual deterioration of his own mind. There is, in my view, a significant chance of Dr MacKinnon taking his own life within the next ten years, despite Dr Klug's skilled help and the support Dr MacKinnon receives from his family. Despite an absence of any family history of the condition, I believe it is most likely constitutional in origin and not caused by the subject incident. In my experience, persons who become psychotic under circumstances like this (in encounter groups) recover with appropriate treatment, and I believe the treatment received was adequate.
His failure to recover is because of constitutional factors and I am of the opinion he would have deteriorated and developed schizophrenia even had he not been exposed to this unfortunate experience. I suggest that the effect of attending the course was to cause his symptoms to emerge earlier and in more florid form.
In other words, even if he had not been exposed to the experience in the BHP course, it is likely his obsessionality (already a problem before the course) would have increased, he would gradually have become less and less efficient as a medical practitioner, and would in time have shown personality oddities which in time would have developed into a clearly recognisable psychotic illness requiring treatment with antipsychotic drugs and preventing him form working."
435 On 17 January 2006, Dr Milton reviewed the Plaintiff again over a period of 2 hours, his wife being present. Dr Milton's report of 3 April 2006 contains these paragraphs:
"In regard to Duromine, he said his father prescribed this for weight loss and gave him a prescription for only one month. However, he said he began taking it three months before the course and his last tablet was on the first day of the course. He recalled passing urine frequently in the time before the course, and drinking six or seven cups of coffee a day, an activity to avoid seeing patients. Clinic staff seemed to think he was hiding in the toilet and used to knock on the toilet door to tell him patients were waiting to see him. He remembered that during the period after being in hospital under Dr Klug he used to go to the Westfield shopping centre "to have a snooze" in the car. He recalled Neil Harvey telling him at some stage that he was working too hard (prior to the course).
Dr MacKinnon recalled that during treatment by Dr Klug, he travelled to BHP in order to prove he could go there. He remembered taking antipsychotic drugs, antidepressants and Valium, and having counselling for anxiety from Mr Rocco Crino (other accounts indicated he saw Dr Crino for treatment of obsessional behaviour as well as anxiety.)
In regard to the current situation, Dr MacKinnon told me he sees a psychologist, Ms Louise Shepherd, once every week or so "to try to get over some of the problems". He said, "I can't watch TV sometimes". Some advertisements he watched showed dogs singing and this disturbed him because he thought it was his psychosis returning. He said Ms Shepherd's treatment for this fear was to get him to write the following sentence many times: "You are not going psychotic, this is just a random event". The technique caused the fear about the dogs singing to disappear, but only temporarily, and he still has it. He avoids science fiction and horror movies.
Early in 2005, he was taking the antipsychotic drug Abilify (aripiprazole). Schizophrenic patients are often non-compliant with antipsychotic medication and, like them, Dr MacKinnon decided he no longer needed that drug. He began to wean himself off it during March 2005, although he continued to take the anti-depressant Endep (amitriptyline).
The usual result of antipsychotic drug non-compliance in schizophrenia is relapse. Dr MacKinnon relapsed, although he described his relapse as "depression", as many schizophrenic patients do, depression being more socially acceptable than schizophrenia. He said, "I just become more and more depressed". It is relevant to note at this point that depression is not provoked by ceasing an antipsychotic drug, and also to note that Dr MacKinnon continued to take an antidepressant, which should have protected him from becoming depressed. The most likely explanation is that ceasing the antipsychotic drug Abilify caused his psychosis to re-emerge, consistent with him suffering schizophrenia.
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He did not tell Dr Klug about ceasing Abilify, so Dr Klug thought his relapse was because this antipsychotic was insufficient - that Dr MacKinnon required an additional antipsychotic drug, and therefore added Seroquel (quetiapine). Later Dr MacKinnon told Dr Klug about having ceased Abilify. and after learning this, Dr Klug weaned him off Seroquel and continued Abilify. For a time, Dr MacKinnon was taking both antipsychotic drugs together and said he felt better, the suicidal ruminations being much less.
This positive response to a higher dose of antipsychotic medication by way of taking two such drugs concurrently favours the diagnosis of schizophrenia. When on only Abilify he went downhill again, so Dr Klug re-introduced Seroquel, with benefit. Dr MacKinnon referred to the way he feels at present, saying, "I don't spend the whole day ruminating how I will kill myself". He firmly denied any feeling that the televison talks to him.
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Dr MacKinnon said he is still registered with the Medical Board. He spoke to the Medical Board and informed them that he has a mental illness and is currently registered as "non-practising". He said the Medical Board staff thanked him for his frankness and said they would leave it to him to make the next step. Dr MacKinnon said he would love to return to medical practice but cannot stand the pressure of people's demands and the feeling of responsibility.
Comment: Such a statement is not typical of the chronically depressed person, who would probably have lost interest in his profession along with most aspects of existence. On the contrary, Dr MacKinnon expressed a continuing love for practising medicine and a wish to do so. A depressed person would also be likely to say he could not work because of lack of energy or because he felt sad or uninterested, but would be less likely to say, as did Dr MacKinnon, that he felt frustrated with people's demands and was troubled by responsibility.
Dr MacKinnon said he enrolled in a college of medical administration, his mentor being Martin Mackerjich. He said the other course he studies is acceptable as credit for qualification in medical administration. He said in order to complete this course he would have to do hospital work but feels he will be unable to cope with it. At some stage he will complete a PhD, probably in about seven years. (He is allowed to do this course because he is working under provisions for disabled people). He said if he does not occupy every minute of his day he stars ruminating (evidently about suicide). These thoughts never leave him.
Comment: In my experience the depressed person usually does not say he ruminates about depression. Rather, he might say he feels bad because he has lost interest in life and deserves to die. In contrast, Dr MacKinnon's suicidal ruminations have an obsessional and somewhat bizarre quality, not as though they arise from feelings of sadness or hopelessness.
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During the interview I made various observation of Dr MacKinnon's presentation. The first of these was as follow: "Keeps ritual movement arms up and down legs - little emotion". The second was well in to the interview and was as follows: "Continues to move hands up and down thighs". The third was, "Continues to move hands (up and down thighs) - no tremor".
Dr MacKinnon was cooperative and gave a reasonable account, but claimed to have forgotten a good deal of his history. He wore spectacles and a moustache and looked overweight, his appearance having changed considerably since 1998. He wore a black baseball cap (he has been losing his hair and was perhaps embarrassed about it). Apart from making ritualistic movements he sat still in a hunched posture. He showed no restlessness or other obvious sign of anxiety. He was not hostile or suspicious. Mrs MacKinnon was pleasant and cooperative, and was in the last stages of her pregnancy.
Dr MacKinnon spoke with reasonable force and energy, although his responses were more limited than when I first saw him and his tone of voice was more uniform, showing fewer inflections. I noted an absence of formal thought disorder. He was more emotionally blunted than when seen earlier. He did not look depressed and did not break down and weep at any time. His manner impressed as bizarre and his mood not congruent with his utterances.
Comment: I consider Dr MacKinnon's presentation to be typical of a person with chronic schizophrenia, including increasing emotional blunting, a reduction in the quality and degree of speech, ritualistic movements, a rather bizarre effect overall, and weight gain. He did not show the retardation, lack of interest, anergia, sadness, feelings of guilt or weeping often seen in the severely depressed person.
436 In evidence in chief to Mr Joseph, Dr Milton expanded upon his opinion as to the Plaintiff's condition, immediately before and during the course:
"JOSEPH: Q. Insofar as you thought the plaintiff was in a prodrome before the course, what do you mean by prodrome in that sense?
A. I mean a state which perhaps has some features of psychosis, perhaps has features of eccentricity, it is a little hard to tell the difference between the two. But it certainly is not a normal state, and it is not an explicable state on the basis of personality conflict or something of that nature. It suggests that there is something going on that is of concern, and perhaps is of concern in the long-term. But that often becomes obvious in retrospect.