(b) absence of diagnosis of PTSD
67The finding that the appellant suffered from PTSD, but that this occurred no earlier than February 2003, was stated in the judgment below at [480]. The reasons for that conclusion were set out at [481]-[495]. However, the whole of that discussion is directed to a search for the earliest professional record of the appellant demonstrating symptoms of PTSD. Nowhere in those pages is there a discussion of the appellant's evidence at trial, nor of his work history as recounted to Dr Canaris, Dr Klug and Dr Lovric.
68The following section dealt with "the assertion that the PTSD was a consequence of undergoing the traumatic events", and was disposed of in three paragraphs, supporting the conclusion that the events were not a substantial contributing factor to the PTSD: at [497]-[499]. That reasoning is closely linked to the first question, namely when the PTSD commenced. The final paragraph, [499], has been set out above; the other two paragraphs were as follows:
"[497] Dr Klug hypothesised that Mr Goodwin's post traumatic stress disorder dates from August 1987, pre-existing the infirmity of Major depression by some fourteen years. Dr Klug's thesis is countered by his own criteria of a temporal connection between a trauma, defined by DSM IV, and diagnosable symptoms of Posttraumatic Stress Disorder (02/04/08, 28.33-48, 29.11-17; exhibit N, O).
[498] Mr Goodwin submits that between 5 July 2001, when he was discharged from New South Wales Police Service, and 30 May 2007, when he was interviewed by Dr Lovric, 'there is no evidence of any traumatic events ... of a kind capable of causing PTSD ... There is no evidence or explanation for how [he] came to be suffering from PTSD in 2007 but not in 1997 when the only evidence about how [PTSD] was caused was traumatic events associated with his work as a police officer' (exhibits W, 5; paragraphs 18, 19, 21, 23, 26, 28, 41, 50, 51, 53, Plaintiff's Submission on Re-hearing)."
69Each paragraph appears to be a freestanding part of the reasoning. It is convenient to address them in turn. The material relied upon at [497] included Exhibits N and O, which were extracts from DSM IV - TR (Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision) for Posttraumatic Stress Disorder and Major Depressive Disorder, respectively. The principal diagnostic criteria for PTSD were stated as follows:
"A The person has been exposed to a traumatic event in which both of the following were present:
(1) 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
(2) the person's response involved intense fear, helplessness or horror. ...
B The traumatic event is persistently reexperienced in one (or more) of the following ways:
(1) recurrent and intrusive distressing recollections of the event ....
(2) recurrent distressing dreams of the event. ...
(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). ...
(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
(5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
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:
(1) efforts to avoid thoughts, feelings or conversations associated with the trauma
(2) efforts to avoid activities, places or people that arouse recollections of the trauma
(3) inability to recall an important aspect of the trauma
(4) markedly diminished interest or participation in significant activities
(5) feeling of detachment or estrangement from others.
(6) restricted range of affect (eg, unable to have loving feelings)
(7) sense of a foreshortened future (eg, does not expect to have a career, marriage, children or a normal life span)
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
(1) difficulty falling or staying asleep
(2) irritability or outbursts of anger
(3) difficulty concentrating
(4) hypervigilance
(5) exaggerated startle response
E. Duration of the disturbance (symptoms of Criteria B, C, and D) is more than 1 month.
F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
...
Specify if:
With Delayed Onset: if onset of symptoms is at least six months after the stressor."
70The passages of transcript relied on by the primary judge came in the cross-examination of Dr Klug. It is convenient, however, to put that evidence in context by noting certain brief aspects of his examination-in-chief. Dr Klug confirmed that he had formed the view in 1999 that the appellant's major depressive disorder arose in the context of chronic and severe marital problems and in the absence of a prior psychiatric history: Tcpt, 2/04/08, p 6(35)-(50). He said that he was not then aware of the various traumatic incidents of which he subsequently became aware: p 7(5)-(15). The following exchange then took place:
"Q. Is there a reason why you might not have inquired with him about the traumas the possibility rather of his having been exposed to traumatic events at that particular stage?
A. It was [remiss] of me, I think, not to ask but I was seeing him for a particular medico legal ... reason and he was about to go to court. I didn't really have the opportunity to see him the second time. So there are restrictions of time. I would say that with about half the police officers or anybody in a similar situation I would assess, in that situation I would see for at least a second time, so that would involve an interview time of about two and a half to three hours. But in retrospect it's remiss not to enquire of somebody with a recurrent major depressive disorder, from any environment, whether they have been traumatised."
71Dr Klug was then taken to his second report of 2 November 2000 in which he raised the possibility of the plaintiff suffering from PTSD. He was asked why and responded at p 8:
"A. Some of his symptoms, he said - and I note on page 2 of my report that he said that in retrospect he grew to hate dead people and 'I can remember them all, even the ones I hadn't gone to' but he said it was particularly bad if he attended scenes involving dead children, especially given that he had children. He was intensely reminded and [became] very anxious about contact with reminders such as sirens, bad weather - because accidents occur in bad weather - scenes on television and the media. He was having bouts of nightmares which were occurring up to nightly at times and which appeared to be worsening and he was in a state of what medically you would say, you would call, autonomic hyper-arousal, a very anxious state with a lot of physical symptoms at night, which is very typical of PTSD.
But he was also having these big sweats as he called them after attending various incidents. Irritability is certainly a prominent feature of PTSD. It also can occur with depressive conditions so - but clearly his irritability was quite high and he'd become very isolated which is also commonly a feature of severe anxiety disorders such as a PTSD. And he was also noting that he would keep driving - when he was a police officer - and sometimes he would just leave the station, go for a walk, get away from the station and that he had hyper-vigilance with respect to potential threats in his environment so he'd become quite hyper-vigilant and ... [those] were the main symptoms and they are all compatible with the diagnosis of either PTSD or a condition along that spectrum.
Q. Is it fair to say, doctor, that at that particular point of time you weren't exactly sure as to whether or not he was in fact suffering from a post-traumatic stress disorder?
A. Clinically, if I were treating him rather than assessing him, I would have managed him as if he had a PTSD but ... in the medico legal setting, it's necessary to try to be more pedantic about criteria that match certain diagnoses so that's why I - I expressed it the way I did."
72Dr Klug was then taken to his report of 24 July 2006 in which he confirmed a diagnosis of PTSD probably together with a major depressive disorder. The following exchange followed:
"Q. So just picking up upon what you had earlier said, how is it that you were able to make the transition from the earlier situation where you weren't able, by way of application of the diagnostic criteria, [to] state categorically that he had the chronic post-traumatic stress disorder in the second report that you were, by 2006, in a position to express that opinion?
A. Well ... he had at that point just the typical presentation of somebody with a chronic PTSD that wasn't responding to treatment. Clinically a major depressive order needs to be actively treated first and then the symptoms of the PTSD addressed and in a person who has such chronicity of a depressive [condition] it is frequently being fuelled by an underlying co-morbid condition, and given his longitudinal history at that point it was clear that he was suffering from a chronic PTSD."
73He was then taken to a further report prepared on 28 November 2006 after he had been provided with further information by the appellant's solicitors and in the conclusion to which he expressed the view that the appellant had suffered from full PTSD probably from about 1993. He was asked the basis for choosing that date (p 10(45)):
"A. He was - there was a particular clinical relevance to an accident, or the scene - sorry, the scene of an accident that he witnessed in '93 which ... involved the death of two elderly women in a car, which he said was T-boned by another vehicle, and he had a frequent preoccupation with images and emotions from attending that scene. So that appears to have been a seminal trauma, with respect to his - the development of his PTSD."
74The following evidence was given at p 12(1)-(10):
"Q. You've just given some evidence about the relationship between traumatic events and the development of post-traumatic stress disorder. Are other life stressors capable of causing post-traumatic stress disorder?
A. By - by definition not. It has to be criterion A that - the DSM system is that it must be defined - it must be a traumatic stressor. So even though people can be exposed to other severe stressors, ... such as an acrimonious divorce, that is not regarded as trauma in the true sense. So by definition, one can't develop PTSD in response to that kind of stress."
75The evidence returned to the question of the comparative effect of other stressors at p 13(40) where the following exchange commenced:
"Q. You've expressed an opinion that from about 1997 on, he was suffering from major depressive disorder?
A. Yes.
Q. By that stage, he had become dysfunctional?
A. Yes.
Q. The reason why he developed major depressive order, as at 1997, was connected, was it, with the traumas or was it connected with something or other else?
A. I think it was substantially connected to the traumas.
Q. I'm interested then in the progression of the major depressive order from that time through to 2000, 2001?
A. Yes.
Q. What was the contribution, if any, of the traumatic events to the major depressive order in that period of time?
A. I believe that they were - were perpetuating factors rather than precipitating or causative factors. So I think that those stressors helped maintain his major depressive condition rather than causing them.
Q. Would he have been suffering from the major depressive disorder that you've spoken about in your reports if he hadn't been exposed to the traumas?
A. I think the likelihood of his developing a major depressive order in response to those stressors, if they were independent of his pre-existing conditions, would have been the same as any member of the population because he had no clear predisposing factors to psychiatric illness, he had no prior history of psychiatric disorder. I'm aware that he had a sister who was severely drug dependent but there was no other family history of psychiatric disorder that I'm aware of. So I think the stats would have been the same for him, at that point, as any member of the population."
76It is convenient to turn next to the two passages in the cross-examination of Dr Klug to which the primary judge referred at [497]. They read as follows:
"Q. I'd like to just ask you a couple of questions about the late onset of the post-traumatic stress disorder.
A. I'm not sure what you mean. You mean delayed post-traumatic stress disorder?
Q. Yes.
A. Because there's no term late onset post-traumatic stress disorder.
Q. Thank you, so delayed. In the present case you received only a full history in 2006 of the events leading to the fully blown condition, correct?
A. Yes.
Q. In 2000, you were prepared to say that there were some post-traumatic symptoms but I take it in the tender of your report you weren't prepared to say that he had PTSD at that stage?
A. That's correct.
...
Q. I understand the final conclusion you've come to is that that was fully blown from 1993. But could it also be a fact that we're looking at a delayed onset?
A. Look, it's remotely possible but that's not my clinical impression.
Q. That didn't enter your calculations?
A. Look, it's - a delayed post-traumatic stress disorder is an unusual diagnosis. It's a fairly rare one.
77It is convenient to include reference to some further questioning, initiated by the primary judge and taken up by counsel for the respondent. Following the cross-examination her Honour asked (p 29(30)):
"... You mentioned divorce as not being the type of stressors that you looked for diagnostically, at least that's what I think you said. What did you mean by that?
A. Your Honour, I think I was being questioned about the - the nature of traumatic stressors and by definition a post-traumatic stress disorder can only be caused by a traumatic stressor. And traumatic stressors are generally defined as ones in which a person's physical integrity or life is at risk or in which they see other people in those situations. Whereas a divorce doesn't qualify for a traumatic stressor even though it may be a severe stressor."
78Counsel for the respondent returned to that topic at p 32(40):
"Q. Her Honour asked you about divorce not being a type of stressor for PTSD.
A. Yes.
Q. It can be the type of stressor that has an effect on, or gives rise to a major depressive disorder though, it is not?
A. That's correct.
Q. As is death of a sister?
A. Yes, that's correct.
Q. In fact I suppose the death of a sister could give rise to both, couldn't it? It could give rise to a post-traumatic stress disorder, depending on -
A. Yeah, it depends on -
Q. - how close you were to the -
A. Well, no, it depends on the mode of death of the sister. So if the sister has died in a terribly traumatic way then it's more likely to be a traumatic stressor if that person had to view the body of the person and so on. ...
Q. It certainly could give rise to a major depressive disorder?
A. That's correct."
79With the assistance of the material identified at [497], it appears that the primary judge rejected Dr Klug's hypothesis that the PTSD dated from "August 1987" on the basis that there were no symptoms at that time and that the temporal criterion required a reasonably close connection between the trauma and the symptoms, referring to a passage she had set out, with apparent approval, at [303]. There is no doubt that the primary judge was entitled to reject Dr Klug's opinion. However, the basis for rejection appears to be the absence of contemporary symptoms prior to the marital breakdown in 1997-1999. In fact, as noted above, whilst Dr Klug may have raised an hypothesis that the appellant was suffering from PTSD as early as 1987, his opinion linked it specifically to an event in 1993 and the immediate and recurring symptoms resulting from that event. For her Honour to reject the medical opinion on that basis required rejection of the symptoms, as opposed to the absence of a contemporaneous written record of the symptoms. To reject the symptoms required confronting the reliability and truthfulness of the appellant's evidence. That task was not undertaken.
80The submission noted at [498] relied upon the same temporal connection upon which her Honour had relied in the previous paragraph. The diagnosis of PTSD in February 2003 required either identification of traumatic events in the period immediately preceding that date, or a rejection of the need for a temporal connection. No traumatic events were identified during the four years preceding that diagnosis, nor was the temporal connection, which appeared to have been accepted in the previous sentence, rejected. (The appellant finally separated from his first wife in January 1999.)
81Precisely what is intended by the reasoning at [499] is unclear. The references at the end to the transcript are all to Dr Klug's evidence; exhibit D included five reports by Dr Klug, together with his curriculum vitae; exhibit J (five pages) included a report and three letters from Dr Sara Murray, the report bearing a page numbering of 318 and 319 (presumably from a bundle of documents at trial); exhibits N and O were extracts from DSM IV, as noted above. There does not appear to be any reference in the transcript to the "hypothesis" recorded by the primary judge. However, Dr Klug did refer in two reports to a report by Dr Canaris noting the appellant's presentation is "strongly consistent with a post traumatic stress disorder" and referring (in the report of 24 July 2006) to Dr Canaris having had interviews with the appellant "of March and February 2003". The reference was erroneous and was corrected in the report of 28 November 2006, where Dr Klug referred to interviews "in March 2002 and February 2003". Even with that correction, the passage at [499] was seriously misleading if it were intended to imply that Dr Klug supported a view that PTSD first presented in February 2003 (putting aside the interview in March 2002) or that there were events shortly prior to those dates which were capable of causing PTSD.
82The second sentence in [499] is even more obscure. Because the questioning of Dr Klug, in which her Honour joined, established that events such as the sister's death, at which the appellant was not present (although he viewed the body), could not constitute a relevant traumatic event for the purposes of PTSD, it might possibly be inferred that the primary judge intended to refer to such events as contributing factors to the appellant's depression. On the other hand, the combination of reference to "traumatic events" other than the work-related traumatic events, and PTSD would run counter to such a correction. There appear to have been no other traumatic events which could have been adequate stressors for the purposes of PTSD. Certainly none were noted in the evidence to which reference was made at [499].
83This analysis of the reasoning of the primary judge is not intended to demonstrate legal error based on some form of mistake or illogicality; rather, it is intended to explain why this Court cannot be satisfied that the primary judge identified and determined the critical issues in dispute.