Statement of Principles

concerning

ACUTE STRESS DISORDER
(Reasonable Hypothesis)

(No. 95 of 2022)

The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986.

Dated                                           21 October 2022

Contents

1 Name

2 Commencement

3 Authority

4 Repeal

5 Application

6 Definitions

7 Kind of injury, disease or death to which this Statement of Principles relates

8 Basis for determining the factors

9 Factors that must exist

10 Relationship to service

11 Factors referring to an injury or disease covered by another Statement of Principles

Schedule 1 - Dictionary

1 Definitions

1               Name

This is the Statement of Principles concerning acute stress disorder (Reasonable Hypothesis) (No. 95 of 2022).

2               Commencement

              This instrument commences on 21 November 2022.

3               Authority

This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986.

4               Repeal

The Statement of Principles concerning acute stress disorder No.41 of 2014 (Federal Register of Legislation No. F2014L00469) made under subsections 196B(2) and (8) of the VEA is repealed.

5               Application

This instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 applies.

6               Definitions

The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument.

7               Kind of injury, disease or death to which this Statement of Principles relates

(1)          This Statement of Principles is about acute stress disorder and death from acute stress disorder.

Meaning of acute stress disorder

(2)          For the purposes of this Statement of Principles, acute stress disorder means a disorder of mental health which meets the following criteria (derived from DSM-5-TR):

1. The individual is exposed to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

(i)            directly experiencing the traumatic event(s);

(ii)         witnessing, in person, the event(s) as it occurred to others;

(iii)       learning that the event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental; or

(iv)        experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (for example, first responders collecting human remains, police officers repeatedly exposed to details of child abuse). This does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related; and

B.            The presence of nine (or more) of the following symptoms from

any of the five categories of intrusion, negative mood,

dissociation, avoidance, and arousal, beginning or worsening

after the traumatic event(s) occurred:

Intrusion Symptoms

(i)            recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed;

(ii)         recurrent distressing dreams in which the content and/or affect of the dream are related to the event(s). In children, there may be frightening dreams without recognisable content;

(iii)       dissociative reactions (for example, flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) In children, trauma-specific re-enactment may occur in play;

(iv)        intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolise or resemble an aspect of the traumatic event(s).

Negative Mood

(i) persistent inability to experience positive emotions (for example, inability to experience happiness, satisfaction, or loving feelings).

Dissociative Symptoms

(i)            an altered sense of the reality of one's surroundings or oneself (for example, seeing oneself from another's perspective, being in a daze, time slowing);

(ii)         inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).

Avoidance Symptoms

(i) efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s);

(ii) efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

Arousal Symptoms

(i) sleep disturbance (for example, difficulty falling or staying asleep, restless sleep);

(ii) irritable behaviour and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects;

(iii) hypervigilance;

(iv) problems with concentration;

(v) exaggerated startle response; and

C.            Duration of the disturbance (symptoms in Criterion 2) is 3 days to 1 month after trauma exposure. Symptoms typically begin immediately after the trauma, but persistence for at least 3 days and up to 1 month is needed to meet disorder criteria; and

D.           The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; and

E.            The disturbance is not attributable to the physiological effects of a substance (for example, medication or alcohol) or another medical condition (for example, mild traumatic brain injury) and is not better explained by brief psychotic disorder.

Note: DSM-5-TR is defined in the Schedule 1 – Dictionary.

Death from acute stress disorder

(3)          For the purposes of this Statement of Principles, acute stress disorder, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's acute stress disorder.

Note: terminal event is defined in the Schedule 1 – Dictionary.

8               Basis for determining the factors

The Repatriation Medical Authority is of the view that there is sound medical‑scientific evidence that indicates that acute stress disorder and death from acute stress disorder can be related to relevant service rendered by veterans, members of Peacekeeping Forces, or members of the Forces under the VEA, or members under the MRCA.

Note: MRCA, relevant service and VEA are defined in the Schedule 1 – Dictionary.

9               Factors that must exist

At least one of the following factors must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting acute stress disorder or death from acute stress disorder with the circumstances of a person's relevant service:

(1)          experiencing a category 1A stressor within the 30 days before the clinical onset of acute stress disorder;

Note: category 1A stressor is defined in the Schedule 1 – Dictionary.

(2)          experiencing a category 1B stressor within the 30 days before the clinical onset of acute stress disorder;

Note: category 1B stressor is defined in the Schedule 1 – Dictionary.

(3)          having a significant other who experiences a category 1A stressor within the 30 days before the clinical onset of acute stress disorder;

Note: category 1A stressor and significant other are defined in the Schedule 1 – Dictionary.

(4)          experiencing the traumatic death of a significant other within the 30 days before the clinical onset of acute stress disorder;

Note: significant other and traumatic death are defined in the Schedule 1 – Dictionary.

(5)          being exposed to repeated or extreme aversive details of severe traumatic events within the 30 days before the clinical onset of acute stress disorder;

Note: being exposed to repeated or extreme aversive details of severe traumatic events is defined in the Schedule 1 – Dictionary.

(6)          experiencing severe childhood abuse within the 30 days before the clinical onset of acute stress disorder;

Note: severe childhood abuse is defined in the Schedule 1 – Dictionary.

(7)          inability to obtain appropriate clinical management for acute stress disorder.

10           Relationship to service

(1)          The existence in a person of any factor referred to in section 9, must be related to the relevant service rendered by the person.

(2)          The factor set out in subsection 9(7) applies only to material contribution to, or aggravation of, acute stress disorder where the person's acute stress disorder was suffered or contracted before or during (but did not arise out of) the person's relevant service.

11           Factors referring to an injury or disease covered by another Statement of Principles

In this Statement of Principles:

(1)          if a factor referred to in section 9 applies in relation to a person; and

(2)          that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(2) of the VEA;

then the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.

Schedule 1 - Dictionary  

Note:               See Section 6

1               Definitions

                  In this instrument:

                                             acute stress disorder—see subsection 7(2).

                               being exposed to repeated or extreme aversive details of severe traumatic events means witnessing a person suffering real, severe, traumatic events (for example, first responders collecting human remains, police officers repeatedly exposed to details of child abuse or drone operators viewing planned strikes) or repeatedly listening to a person's account of their exposure to severe traumatic events. This definition includes media exposure of the traumatic event (for example, electronic media, television images or photographs) where viewing these images is a work requirement.

                               category 1A stressor means one of the following severe traumatic events:

(a)          experiencing a life-threatening event;

(b)          being subject to a serious physical attack or assault including rape and sexual molestation; or

(c)          being threatened with a weapon, being held captive, being kidnapped or being tortured.

                               category 1B stressor means one of the following severe traumatic events:

(a)          killing or maiming a person;

(b)          being an eyewitness to a person being killed or critically injured;

(c)          being an eyewitness to atrocities inflicted on another person;

(d)          participating in the clearance of a corpse or a critically injured casualty; or

(e)          viewing a corpse or a critically injured casualty as an eyewitness.

Note: corpse and eyewitness are also defined in the Schedule 1 – Dictionary.

                               corpse means the human remains or body parts of one or more persons who have met a violent or horrific death.

Note: Examples of a violent or horrific death may include death due to suicide, gunshot, improvised explosive devices, natural and technological disasters, terrorist attacks or motor vehicle accidents. Seeing a closed body bag or viewing a body in an open-casket coffin are excluded from this definition.

                               DSM-5-TR means the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2022.

                               eyewitness means a person who experiences an incident first hand and can give direct evidence of it. This excludes persons exposed only to public broadcasting or mass media coverage of the incident.

                               MRCA means the Military Rehabilitation and Compensation Act 2004.

                               relevant service means:

(a)          operational service under the VEA;

(b)          peacekeeping service under the VEA;

(c)          hazardous service under the VEA;

(d)          British nuclear test defence service under the VEA;

(e)          warlike service under the MRCA; or

(f)           non-warlike service under the MRCA.

Note: MRCA and VEA are also defined in the Schedule 1 - Dictionary.

                               severe childhood abuse means:

(a)          serious physical, emotional, psychological or sexual harm whilst a child aged under 16 years; or

(b)          neglect involving a serious failure to provide the necessities for health, physical and emotional development, or wellbeing whilst a child aged under 16 years;

where such serious harm or neglect has been perpetrated by a parent, a care provider, an adult who works with or around that child, or any other adult in contact with that child.

                               significant other means a person who has a close family bond or a close personal relationship and is important or influential in one's life.

                               terminal event means the proximate or ultimate cause of death and includes the following:

(a)           pneumonia;

(b)           respiratory failure;

(c)           cardiac arrest;

(d)           circulatory failure; or

(e)           cessation of brain function.

                               traumatic death means death which occurs in sudden, violent or traumatic circumstances such as homicide, suicide or an accidental death.

                               VEA means the Veterans' Entitlements Act 1986.