The definitions of post-traumatic stress disorder having been established to Bavistock’s satisfaction, he moved on. ‘So, in the definition you prefer, Dr Ainsley, the symptoms include flashbacks, panic attacks, depression, guilt, chronic anxiety, insomnia, mood swings, phobias, lack of concentration, stress avoidance. Would you expect to find all of these symptoms in every case?’
‘No. But I would expect to find a good number of them, particularly flashbacks, mood swings and stress avoidance strategies. They’re central to any diagnosis of PTSD.’
‘Would it be true to say that the more symptoms present, the more confident you would be of your diagnosis?’
‘No. The nature and severity of the main symptoms would be the most important consideration.’
‘Now, Dr Ainsley, could you tell us how it was that Mr Deacon came to consult you in the first instance?’
It had always been unrealistic to hope that this issue wouldn’t be explored in open court. Hugh’s error, so easily made at the time, so obviously wrong in retrospect, was already there in the evidence bundle for all parties to see. It would be an inept defence that didn’t bring it more fully to the judge’s
attention. The only question now was how much salt Bavistock would rub into the wound.
Ainsley replied, ‘I got a letter from Tom Deacon’s solicitors, asking if I would give an opinion as to his condition.’
Tom whispered fretfully in Hugh’s ear, ‘What’s this got to do with anything?’
Non-essential conversation was discouraged in court and Hugh automatically glanced at the judge before scribbling,
My error in original letter
. Tom read it and shrugged before crossing his arms tightly across his chest.
Bavistock was saying, ‘Didn’t they go further than that? Didn’t Messrs Dimmock Marsh say in their letter, I quote, “We fear Mr Deacon is suffering from an acute post-traumatic stress disorder and would be grateful for an opinion”?’
‘You may be right – it’s four years ago now.’
‘If I could refer you to page thirteen in the evidence bundle, perhaps you would like to refresh your memory.’
Hugh didn’t need to look at his copy of the letter to see it clearly in his mind, complete with offending phrase and his signature at the bottom.
When Ainsley had read the letter, Bavistock said, ‘So having received this letter you were in no doubt as to the diagnosis they wanted?’
Desmond got to his feet. ‘My Lord, could it be noted that the letter also asked Dr Ainsley for advice on treatment and rehabilitation?’
The judge nodded. ‘It is noted, Mr Riley.’
It was a loyal effort on Desmond’s part, but there was no escaping the basic mistake. Bavistock hammered it home. ‘It was clear what they were hoping for in the way of a diagnosis?’
‘Given the nature of Mr Deacon’s experience, such a diagnosis would always be a possibility. That said, I would never be influenced by what people were hoping for,’ Ainsley said with a puff of self-importance, ‘only by what I find.’
‘Indeed,’ Bavistock said with a fleeting mechanical smile.
‘But of course post-traumatic stress disorder is actionable under the law, while a grief reaction, however intense, is not. When the patient is aware that grief alone won’t be sufficient to win him compensation, that only PTSD will do, could that not influence him, consciously or subconsciously, into emphasising certain symptoms that would improve his chances of getting the more advantageous diagnosis?’
Ainsley paused before saying with obvious reluctance, ‘In theory it’s possible, yes. But I don’t believe that happened in this case.’
At Hugh’s side Tom was rubbing his forehead in harsh repetitive movements, the tension radiating from him like a heat.
‘And is it also possible that a patient who has learnt about the symptoms of PTSD might persuade himself he has new symptoms that weren’t there before?’
‘Again, it might be possible in theory. But in my opinion it didn’t happen in this case.’
‘Oh? And why would that be?’
‘The descriptions he gave of his symptoms were too spontaneous, too vivid.’
Bavistock looked doubtful. ‘How would that rule out the possibility of exaggeration or amplification?’
‘Well, it would have required an extraordinary degree of imagination on his part to describe the symptoms with such accuracy.’
‘What, even if he’d studied such symptoms in depth?’
‘I would say so, yes.’
Bavistock raised his eyebrows slightly. ‘Now, you have described Mr Deacon’s symptoms in your statement – if I can refer you to page seventeen, paragraph three.’ When Ainsley had found his place, Bavistock went on, ‘Mr Deacon seems to have every possible symptom of PTSD. Nothing missing at all. What you might call a textbook case. Would you agree?’
‘Well . . . In simple terms, yes.’
‘In any terms, surely?’
For the first time Ainsley showed faint irritation. ‘Yes,’ he said shortly.
‘Isn’t it odd that one person should have such a comprehensive list of symptoms?’
‘Not at all.’
‘But you’ve just told us that you wouldn’t expect to find the full range of symptoms in every case.’
Ainsley seemed to falter, and for a moment Hugh thought he was going the same way as the cognitive behavioural therapist Munro. But then Ainsley straightened his back and said crisply, ‘I meant only that it was uncommon. I didn’t mean it was impossible.’
‘You didn’t think it strange at the time?’
‘No.’
‘It didn’t occur to you that Mr Deacon might have imagined a fuller range of symptoms than he actually had?’
‘As I’ve said, I think it unlikely.’
Adopting one of his coping strategies, Tom hunched forward over the table and, resting his forehead on his fingertips, screwed his eyes tight shut, as if to blank everything out.
Moving on, Bavistock leafed through his notes. ‘Now, you have diagnosed Mr Deacon as having severe PTSD. Could you tell us what other degrees of severity there are?’
‘After severe, there’s moderately severe, moderate, and minor.’
‘Could you define the moderate category for us, please?’
Ainsley thought he must have misheard. ‘Moderate?’
‘Yes, moderate.’
‘This is when the injured person has largely recovered, and any continuing effects are not grossly disabling.’
‘Not grossly disabling?’ Bavistock echoed.
‘Correct.’
‘So a moderate case could be more difficult to diagnose?’
‘It could be. But the critical factor is the exposure of the
patient to a traumatic event that falls outside the normal range of human experience. If the patient’s condition can be traced back to that, then they can said to be suffering from PTSD.’
‘But if this link isn’t spotted, if the patient himself doesn’t realise why he’s unwell – or indeed is in denial about it – then a moderate case might well go undiagnosed?’
A minute hesitation. ‘It’s possible, yes.’
‘Could indeed be misdiagnosed?’
‘That’s possible too.’
‘It might be diagnosed as depression, for example?’
Ainsley had the wary look of someone who realises he’s being backed into a corner. ‘It’s just possible, yes.’
‘Only “just possible”? Surely if a diagnosis of post-traumatic stress disorder is missed, then depression would be the obvious alternative?’
‘Depression is only one of several alternatives.’
‘Name a few, if you would.’
With the confidence of someone returning to safe ground, Ainsley went briskly through his list. ‘Adjustment disorder, acute stress disorder, obsessive-compulsive disorder, conversion disorder – not to mention any number of psychosomatic disorders.’
‘But these are diagnoses that would only be made by a specialist like yourself, would they not? An ordinary GP would not be qualified to give such diagnoses?’
Ainsley was forced to agree.
Behind the spread of his hands Tom still had his eyes squeezed tight shut, but the dampness had reappeared on his temples and his jaw muscles were flickering angrily. Hugh signalled to Isabel for water and, touching Tom’s arm, put the glass by his elbow, but if he noticed he gave no sign.
Bavistock was saying, ‘If the patient doesn’t get as far as a psychiatrist, if he only gets to see his GP, then depression would be the most likely diagnosis, would it not?’
‘It might be.’ Then, relenting, Ainsley added, ‘Yes, it would be the most likely.’
‘Now, in the annals of medical history, PTSD is a fairly recent condition, is it not?’
‘The term itself is relatively recent, yes. But medically, the condition has been recognised for a long time, since the nineteenth century in fact, but under different names.’
‘Indeed . . . And what sort of names would have been most common?’
‘Well . . . shell shock . . . neurasthenia . . . war neurosis . . . battle stress . . . nervous shock . . . survivor syndrome . . .’
‘It was seen, then, as a condition that arose mainly from combat situations?’
‘War was certainly accepted as one of the most likely causes of the condition. But it was recognised in civilian life too, in mining accidents, train accidents, and so on, and then it was known as nervous shock or fright neurosis, among other things.’
‘But shell shock, combat stress, combat neurosis were the most common terms. I put it to you that the medical community has long recognised, whether under the old names or the new, that PTSD is most commonly seen in people exposed to the horrors of war.’
‘I couldn’t say most commonly. The statistics would be hard to establish.’
‘Well – frequently, then? Would you agree that the condition was, and still is,
frequently
seen in people exposed to the horrors of war?’
Ainsley paused, distrusting the semantics. ‘I would only say that it’s seen
regularly
in combatants.’
‘Did Mr Deacon mention that he’d been treated for depression at various times in the eight years after leaving the Army and before the accident that killed his daughter?’
Tom sucked in his breath with an audible hiss and shook his head.
‘He said he’d found it difficult to adjust to civilian life. And yes, he mentioned taking anti-depressants.’
‘He didn’t say what precisely was depressing him?’
‘Well, adjusting to civilian life, as I’ve just said.’
‘But what was it about civilian life that was giving him difficulty?’
‘He wasn’t specific.’
Hugh had a good idea where this was leading and hoped that Ainsley did too.
‘Isn’t that surprising?’ Bavistock suggested. ‘Wouldn’t you expect him to talk about what exactly had been worrying him at that time?’
‘Not necessarily.’ Then, forgetting the golden rule of the expert witness, Ainsley volunteered additional information. ‘People with depression often can’t identify anything in particular that’s getting them down.’
‘So he may have
thought
it was his difficulty in adjusting to civilian life that was causing his depression when in fact it was something else altogether?’
Too late, Ainsley saw the trap. He said tersely, ‘Well, it’s virtually impossible to separate depression from life events. Cause and effect feed off each other. So depression might cause someone to lose his job, then the loss of the job itself triggers further depression.’
‘And Mr Deacon certainly lost his job on several occasions in the period after leaving the Army and before the accident. Did he mention that to you?’
‘He mentioned losing at least one job.’
‘But not several?’
‘I don’t recall him telling me that, no.’
‘Did he mention that he’d been a heavy drinker at that time?’
‘He said he’d had periods of heavy drinking.’
‘Did he mention that, by his own admission, he was a regular cannabis user?’
Ainsley thought for a moment. ‘That didn’t come up, no.’
‘Or that his marriage had experienced difficulties?’
‘He talked about ups and downs in his marriage, yes.’
‘No more detail than that?’
‘Not concerning the period you mention, no.’
Making his point, Bavistock said, ‘So the period of Mr Deacon’s life between leaving the Army and the car accident effectively went unexamined by you.’
‘With the exceptions I’ve already mentioned, the subject simply never arose.’
‘But you see what I’m suggesting, don’t you, Dr Ainsley? That the difficulties and depression Mr Deacon had in this eight-year period could have stemmed from post-traumatic stress related to his active service, and that you would have been unaware of the fact.’
‘I can only report on what I find, and as I’ve already stated he gave no indication of pre-existing PTSD.’
In the pause that followed, the judge suggested it might be a convenient time to rise for lunch. Emerging slowly from his self-imposed trance, Tom got up and went down into the body of the court to see Ainsley, who greeted him with a smile and an upturning of both palms which he converted into a handshake, his left hand laid over Tom’s, so that Hugh was reminded of a priest giving benediction.
Desmond turned to Hugh and murmured, ‘A couple of points we could have done without, but no serious damage.’
‘Will you re-examine?’
Desmond plucked the wig off his head and stuffed it into his tote bag. ‘I would say so, yes. But let’s see what the afternoon brings.’ Then, because he liked his food, he said keenly, ‘How about lunch? There’s a nice little place over the road.’
‘And the conference with Tom?’
‘Oh, while we eat, don’t you think?’
Aware that the opposition were still in court, Hugh kept his voice very low. ‘It’s Price he wants to discuss with you.’
‘I rather thought it might be.’
‘He wants to tell the judge his side of the story.’
‘A perfectly natural impulse.’ Desmond’s gaze travelled across to Tom. ‘But one that is probably best resisted.’
‘More harm than good?’
‘There has to be a risk, doesn’t there?’ Desmond glanced at the clock. ‘I don’t mean to rush you, but we should get going if we want a table.’
Hugh went down into the body of the court, meaning to keep out of earshot, only to hear Tom say in a tight voice, ‘But then I can’t get to sleep again . . .’
Looking up, Ainsley narrowed his eyes at Hugh, as if to confirm he wasn’t going to be much longer, then bending his head, touching a light hand to Tom’s arm, spoke to him in a soothing voice. Tom gave a series of sharp nods, then as they moved apart turned towards Hugh with a look of unguarded distress.