Acute Stress Disorder — DVA claim example

Diagnostic Assessment — Acute Stress Disorder

Example 1 of 1 · fictitious patient (Veteran L)

Diagnostic Assessment

Acute Stress Disorder

BOP Code: 96 of 2022 (Acute Stress Disorder)
RH Code: 95 of 2022 (Acute Stress Disorder)

ADF History

Veteran L, date of birth 03 February 1955, Royal Australian Navy, enlisted as a Junior Recruit 11 February 1970 at the age of 15, later Seaman (Boatswain's Mate), discharged at his own request as a Leading Seaman 09 February 1979. Operational service: Vietnam, service in Vietnamese waters aboard a fast troop transport, 05 January 1971 to 14 January 1971 (warlike).

Occupational History

As a junior recruit and then an Ordinary Seaman (Junior) in the seaman branch, the veteran lived in crowded mess decks with adult sailors, worked long watches on deck and in boats, and handled cargo nets, lines and landing craft alongside the ship in all weather. Junior sailors of the period were the lowest in the shipboard hierarchy and were exposed to initiation rituals, bastardisation and physical punishment by senior sailors, with little supervision by officers and no confidential reporting pathway.

On the troop transport voyages to Vietnam the seaman branch unloaded vehicles, ammunition and stores into landing craft at an exposed anchorage, often at night and in swell, and stood anti-swimmer sentry watches with scare charges against enemy combat swimmers. Junior sailors were also detailed to help in the sick bay with wounded and sick soldiers embarked for the return voyage. Psychological care at sea was limited to the ship's medical officer and sedative medication.

History

Veteran L, who enlisted in the Royal Australian Navy as a 15-year-old junior recruit and served as a junior seaman aboard a fast troop transport, was repeatedly physically and sexually assaulted by adult senior sailors in December 1970 and January 1971 and, on warlike service at the Vung Tau anchorage on 10 and 11 January 1971, nearly drowned, saw his closest friend crushed to death, recovered his body and killed an enemy swimmer. He developed acute stress disorder on 12 January 1971, recorded by the ship's medical officer on 15 January 1971, which worsened over the following weeks without psychological treatment and progressed to posttraumatic stress disorder.

Timeline

• 11 Feb 1970 — The veteran enlisted in the Royal Australian Navy as a junior recruit at the age of 15 and began twelve months of training at a naval junior recruit training establishment in Western Australia. His entry medical examination recorded no psychiatric history, normal development and no prior contact with mental health services. His school and family history were unremarkable. "fit, no psychiatric history"
• 14 Dec 1970 — On completion of junior recruit training he was posted as an Ordinary Seaman (Junior), aged 15 years and 10 months, to a fast troop transport preparing for a voyage to Vietnam. The joining medical examination recorded him as medically fit for sea service, sleeping well and with normal mood. This is the last record showing him free of psychological symptoms. "fit for sea service"
• 23 Dec 1970 — He attended the sick bay with bruising of the left chest wall and both upper arms and a split lip, initially stating he had fallen down a ladder. On 22 December 1970, while the ship was alongside in Sydney, two adult senior sailors had held him down in a storeroom, beaten him and sexually assaulted him as a mess-deck initiation. The assaults were repeated on 30 December 1970 and 06 January 1971 during the passage north. The ship's medical officer later recorded his disclosure and noted that he was 15 years old at the time. "chest bruising, states fell, aged 15"
• 10 Jan 1971 — At the Vung Tau anchorage, during night unloading in a heavy swell, a landing craft surged against the ship's side. The veteran was knocked from the cargo pontoon into the water between the landing craft and the hull, went under twice and was pulled out semi-conscious after about four minutes. His closest friend, a junior seaman from the same recruit intake, was crushed between the landing craft and the hull in front of him and died at the scene. The veteran then helped lift his friend's body from the water and carry it to the sick bay. The ship's log and sick bay register record the near-drowning and the death. "near drowning, aspirated seawater, observed"
• 15 Jan 1971 — Three days after the ship sailed from Vung Tau the veteran was brought to the sick bay by his divisional petty officer. The medical officer recorded that since 12 January he had not slept more than two hours a night, woke screaming from dreams of the landing craft, startled at the sound of the boats, felt in a daze as if watching himself from outside, could not recall parts of the night of 10 January, avoided the upper deck and his friend's mess, and had been in fights. On 11 January, on anti-swimmer sentry, he had thrown the scare charges that killed an enemy swimmer whose body was recovered alongside the next morning, and on the same day he received a signal that his older brother, an infantry soldier, had been critically wounded by a mine on 05 January. He had also been assisting in the sick bay since 09 January with wounded soldiers embarked for the return voyage. Chlordiazepoxide was prescribed and he was returned to watchkeeping duties. "nightmares, startle, dazed, not eating"
• 21 Jan 1971 — The medical officer recorded a marked worsening. The veteran had collapsed in a panic on the upper deck during a boat drill, was unable to remain in the mess, and was now sleeping in a passageway. Chlordiazepoxide was increased. No psychiatrist or psychologist was available at sea, and on arrival in Sydney he was granted five days' leave without referral. The symptoms continued beyond one month and were later recognised as having progressed to posttraumatic stress disorder. "worse, panic, sedation increased"
• 15 Mar 1973 — He was referred for the first time to a naval psychiatrist after repeated absences, heavy drinking and fights. The psychiatrist recorded a war neurosis with nightmares and startle dating from the voyage to Vietnam, but did not record the assaults. He was treated with sedatives and returned to duty, and was discharged at his own request in February 1979. "war neurosis since Vietnam voyage"
• 18 Jun 2024 — A consultant psychiatrist reviewed the contemporaneous sick bay records, the ship's log and the veteran's account, and diagnosed acute stress disorder with onset on 12 January 1971, meeting the DSM-5-TR criteria, which progressed to chronic posttraumatic stress disorder after one month. The psychiatrist recorded that the assaults in December 1970 and January 1971 occurred when he was 15 years old, and that the veteran had disclosed them fully for the first time in 2023. "acute stress disorder, January 1971"

Symptoms

At onset on 12 January 1971 the veteran had intrusive memories of his friend's death and the near-drowning, nightmares of the landing craft, flashbacks when he heard boat engines, a dazed sense of unreality and of watching himself from outside, amnesia for parts of the night of 10 January, avoidance of the upper deck and of his friend's mess, insomnia of two hours a night, irritability and fighting, hypervigilance, poor concentration on watch and an exaggerated startle response. He was unable to experience any positive emotion and stopped eating. The symptoms worsened over the following three weeks, with panic on the upper deck, and they persisted beyond one month.

He now reports chronic nightmares, intrusive memories of the assaults and of the anchorage, avoidance of boats, the sea and crowded enclosed spaces, emotional numbness, poor sleep, irritability and long-standing difficulty trusting men in authority. These ongoing symptoms are attributed to the posttraumatic stress disorder into which the acute stress disorder progressed.

Imaging

No imaging is required to establish this diagnosis.

Onset Date

The most likely date of onset of this condition is 12 Jan 1971.

At that date the veteran was a 15-year-old Ordinary Seaman (Junior) aboard a fast troop transport on warlike service in Vietnamese waters, on the day the ship sailed from the Vung Tau anchorage. In the preceding three weeks he had been repeatedly assaulted by adult senior sailors, had nearly drowned, had seen his closest friend crushed to death and recovered his body, had killed an enemy swimmer and had learned that his brother was critically wounded.

This date is appropriate because his joining medical examination on 14 December 1970 recorded normal sleep and mood, and the medical officer's entry of 15 January 1971 records that the nightmares, insomnia, dissociation and startle began on 12 January 1971, the day after the last of the traumatic events, three days before he was brought to the sick bay. The symptoms continued for more than three days and then for about four weeks, and the clinical picture meets the duration criterion for acute stress disorder before progressing to posttraumatic stress disorder.

For every causative factor, the 30 days before onset run from 13 Dec 1970 to 12 Jan 1971. Within that window the veteran was physically and sexually assaulted on 22 December 1970, 30 December 1970 and 06 January 1971 while aged 15; nearly drowned on 10 January 1971; saw his friend killed and helped recover his body on 10 January 1971; killed an enemy swimmer on 11 January 1971; learned on 11 January 1971 that his brother had been critically wounded by a mine on 05 January 1971; and assisted in the sick bay with wounded soldiers from 09 January 1971, hearing their accounts repeatedly. He was serving full time throughout this period, aboard the ship in Australia from 14 December 1970 and on warlike service in Vietnamese waters from 05 January 1971.

For the worsening factor, the period after onset runs from 12 Jan 1971 to the documented worsening on 21 Jan 1971 and beyond, during which no psychological treatment was available at sea and he was kept on watchkeeping duties.

1. What is the formal diagnosis of the condition claimed above?

The formal diagnosis is Acute Stress Disorder (ICD-10-AM F43.0), under the Statements of Principles concerning acute stress disorder, Balance of Probabilities No. 96 of 2022 and Reasonable Hypothesis No. 95 of 2022.

Acute stress disorder is a disorder of mental health that follows exposure to actual or threatened death, serious injury or sexual violence. It is characterised by intrusion symptoms, negative mood, dissociative symptoms, avoidance and arousal that begin or worsen after the traumatic event and last from three days to one month. It causes clinically significant distress and impairment, and when symptoms persist beyond one month it is commonly followed by posttraumatic stress disorder.

The disorder followed repeated physical and sexual assaults on the veteran as a 15-year-old junior sailor in December 1970 and January 1971 and the traumatic events of his warlike service at the Vung Tau anchorage on 10 and 11 January 1971. It began on 12 January 1971, was recorded by the ship's medical officer on 15 January 1971 and worsened by 21 January 1971.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition?

12 January 1971.

When did the veteran first present to a health / medical provider for this condition?

15 January 1971.

When was the condition confirmed / formally diagnosed?

18 June 2024.

When did the veteran first present to you (or your practice) for this condition?

20 March 2025.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?

The diagnosis was made by a consultant psychiatrist on 18 June 2024 from the contemporaneous sick bay records of 15 and 21 January 1971, the ship's log and a structured interview. The records document exposure to actual death, threatened death and sexual violence (Criterion A), and at least thirteen of the specified symptoms across all five categories, including intrusive memories, distressing dreams, flashbacks, persistent inability to experience positive emotions, an altered sense of reality, dissociative amnesia, avoidance of memories and reminders, insomnia, irritable behaviour, hypervigilance, poor concentration and exaggerated startle (Criterion B). The symptoms began on 12 January 1971 and lasted about four weeks before progressing (Criterion C), caused marked impairment of his watchkeeping and mess-deck functioning (Criterion D), and were not explained by a substance, a head injury or a psychotic disorder (Criterion E). This meets the Statement of Principles definition of acute stress disorder, which is derived from DSM-5-TR.

The clinical course was consistent with the diagnosis: the symptoms began immediately after the traumatic events, escalated over the following three weeks without treatment, and persisted beyond one month as posttraumatic stress disorder. The psychiatrist confirmed that the amnesia was dissociative, as there was no loss of consciousness from head injury, and that the near-drowning had not caused a hypoxic brain injury.

4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.

Legislation: the clinical onset of this condition was on 12 January 1971, before 1 July 2004, while the veteran was on warlike service in Vietnamese waters. Service in Vietnam is operational service under the Veterans' Entitlements Act 1986 (VEA), so this is a VEA claim and the Statements of Principles apply. The Reasonable Hypothesis instrument applies to the veteran's operational service in Vietnam from 05 January 1971, where the near-drowning, his friend's death, the killing of the enemy swimmer, the news of his brother's wounding, the work in the sick bay and the last of the assaults occurred. The Balance of Probabilities instrument applies to non-operational service; for the assaults of 22 and 30 December 1970, which occurred before the ship entered the operational area, the claim is also available under the Safety, Rehabilitation and Compensation (Defence-related Claims) Act 1988 (DRCA), under which the Statements of Principles do not bind but every factor is still analysed.

Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack. This is particularly so for sexual assaults on junior sailors in this period, which were rarely reported or recorded at the time.

Balance of Probabilities — Statement of Principles concerning Acute Stress Disorder, No. 96 of 2022

Causative factors

Factor 9(1): experiencing a category 1A stressor within the 30 days before the clinical onset of acute stress disorder; — MET

- On 22 December 1970, while the ship was alongside in Sydney before sailing, two adult senior sailors held the veteran down in a storeroom, beat him and sexually assaulted him as a mess-deck initiation, and the assault was repeated on 30 December 1970 during the passage north. Being subject to a serious physical attack or assault, including rape and sexual molestation, is a category 1A stressor. The assaults occurred 21 and 13 days before onset, within the 30 days from 13 December 1970 to 12 January 1971, and arose from the conditions of his service as a junior sailor living in a mess with adult sailors. The sick bay record of 23 December 1970 documents the injuries.

Factor 9(2): experiencing a category 1B stressor within the 30 days before the clinical onset of acute stress disorder; — MET

- On 10 January 1971, two days before onset, the veteran was an eyewitness to his friend being crushed to death between a landing craft and the ship's side while unloading cargo, and he then helped lift the body from the water and carry it to the sick bay. Being an eyewitness to a person being killed, participating in the clearance of a corpse and viewing a corpse as an eyewitness are each category 1B stressors. The events occurred in the course of his seaman duties and are recorded in the ship's log and the sick bay register.

Factor 9(3): having a significant other who experiences a category 1A stressor within the 30 days before the clinical onset of acute stress disorder; — MET

- The veteran's closest friend, a junior seaman from the same recruit intake with whom he had trained and shared a mess for eleven months, experienced a life-threatening event when he was crushed by the landing craft on 10 January 1971. His older brother, with whom he was close and who had encouraged him to join the services, was critically wounded by a mine on 05 January 1971. Both are significant others, and both events, being life-threatening, are category 1A stressors. They occurred 2 and 7 days before onset, and the veteran learned of his brother's wounding by signal on 11 January 1971 while serving aboard the ship.

Factor 9(4): experiencing the traumatic death of a significant other within the 30 days before the clinical onset of acute stress disorder; — MET

- The veteran's closest friend died a violent, accidental death on 10 January 1971, two days before onset, crushed between a landing craft and the ship's hull during night cargo work. The veteran was beside him when it happened. The friend was a significant other: they had enlisted on the same day, trained together for eleven months and been posted to the ship together. The death occurred during the cargo duties both were performing.

Factor 9(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; — MET

- From 09 January 1971 the veteran was detailed to assist the medical officer in the sick bay with fourteen wounded soldiers embarked for the return voyage, including two with traumatic amputations from mines. Over four days he dressed their wounds and repeatedly listened to their accounts of the mine incidents and the deaths of their mates, and on 10 January 1971 he witnessed his friend's crush injuries at first hand. This was extreme and repeated exposure to the aversive details of severe traumatic events as a work requirement, within the 30 days before onset on 12 January 1971.

Factor 9(6): experiencing severe childhood abuse within the 30 days before the clinical onset of acute stress disorder; — MET

- The veteran was born on 03 February 1955 and was 15 years old when adult senior sailors beat and sexually assaulted him on 22 December 1970, 30 December 1970 and 06 January 1971, and subjected him to ongoing threats and humiliation in the mess between the assaults. This was serious physical, psychological and sexual harm to a child aged under 16 years, perpetrated by adults in contact with him, and it occurred within the 30 days before onset, from 13 December 1970 to 12 January 1971. It arose directly from the Navy's enlistment of junior recruits at 15 and their accommodation with adult sailors, and is the kind of abuse later acknowledged by the Defence Abuse Response Taskforce.

Worsening factors

Factor 9(7): inability to obtain appropriate clinical management for acute stress disorder. — MET

- After the medical officer recorded the disorder on 15 January 1971, no psychiatrist, psychologist or chaplain-led debriefing was available aboard, and the only treatment was chlordiazepoxide while the veteran was returned to watchkeeping and anti-swimmer sentry duties alongside the men who had assaulted him. The disorder worsened by 21 January 1971, with panic on the upper deck and inability to remain in the mess. On return to Sydney he was sent on leave without referral, and he did not see a psychiatrist until 15 March 1973. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management, and it contributed to the disorder persisting and progressing.

Reasonable Hypothesis — Statement of Principles concerning Acute Stress Disorder, No. 95 of 2022

Causative factors

Factor 9(1): experiencing a category 1A stressor within the 30 days before the clinical onset of acute stress disorder; — MET

- On warlike service at the Vung Tau anchorage on 10 January 1971, two days before onset, the veteran was knocked into the water between a surging landing craft and the ship's hull, went under twice and was pulled out semi-conscious after about four minutes. This was a life-threatening event, a category 1A stressor, recorded in the sick bay register as a near-drowning with aspiration of seawater. The last of the sexual assaults by senior sailors, on 06 January 1971, also occurred after the ship had entered Vietnamese waters on 05 January 1971.

Factor 9(2): experiencing a category 1B stressor within the 30 days before the clinical onset of acute stress disorder; — MET

- On warlike service at the Vung Tau anchorage the veteran saw his friend crushed to death on 10 January 1971 and helped recover his body. On the night of 11 January 1971, standing anti-swimmer sentry, he threw the scare charges at an enemy combat swimmer approaching the hull, and the swimmer's body was recovered alongside the next morning. Killing a person, being an eyewitness to a person being killed and participating in the clearance of a corpse are each category 1B stressors, and all occurred within the 30 days before onset on 12 January 1971, in the course of his operational duties.

Factor 9(3): having a significant other who experiences a category 1A stressor within the 30 days before the clinical onset of acute stress disorder; — MET

- The veteran's older brother, an infantry soldier on warlike service in Vietnam, was critically wounded by a mine on 05 January 1971, and his closest friend experienced a life-threatening crush injury at the anchorage on 10 January 1971. Both are significant others and both events were life-threatening category 1A stressors within the 30 days before onset. The veteran learned of his brother's wounding by signal on 11 January 1971 while on warlike service aboard the ship, and witnessed his friend's injury during operational cargo work.

Factor 9(4): experiencing the traumatic death of a significant other within the 30 days before the clinical onset of acute stress disorder; — MET

- The veteran's closest friend died violently on 10 January 1971 at the Vung Tau anchorage, crushed between a landing craft and the hull during night unloading of stores for the Australian task force. The death occurred on warlike service, two days before onset, during duties the two were performing together.

Factor 9(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; — MET

- On warlike service in Vietnamese waters from 09 January 1971 the veteran was detailed to the sick bay to help care for fourteen wounded soldiers being repatriated, including amputees from mine incidents. He repeatedly heard their accounts of the incidents and of mates killed, dressed their wounds, and on 10 January 1971 saw his friend's fatal crush injuries. This repeated and extreme exposure to the aversive details of severe traumatic events was a requirement of his duties and occurred within the 30 days before onset.

Factor 9(6): experiencing severe childhood abuse within the 30 days before the clinical onset of acute stress disorder; — MET

- The veteran was 15 years old when adult senior sailors sexually assaulted him for the third time on 06 January 1971, after the ship had entered Vietnamese waters on warlike service, following the assaults of 22 and 30 December 1970. The abuse was serious physical, psychological and sexual harm to a child aged under 16 years, perpetrated by adults in contact with him, within the 30 days before onset on 12 January 1971. It occurred aboard the ship during operational service and continued as threats until he left the ship.

Worsening factors

Factor 9(7): inability to obtain appropriate clinical management for acute stress disorder. — MET

- While still on warlike service and on the return voyage, the veteran had no access to a psychiatrist or psychologist. He received only chlordiazepoxide from 15 January 1971 and was kept on anti-swimmer and deck watches, and the disorder worsened markedly by 21 January 1971. Operational constraints at sea prevented appropriate assessment and treatment, and no referral followed on return to Australia. This is an inability to obtain appropriate clinical management.

The % contribution of the causes is 100% and significant.

Sequelae

The acute stress disorder progressed after one month to chronic posttraumatic stress disorder, which a consultant psychiatrist confirmed on 18 June 2024. The veteran also developed alcohol use disorder from 1972, recorded by the naval psychiatrist in March 1973 as drinking to manage nightmares, and has long-standing insomnia. These conditions are sequelae of the acute stress disorder and of the same service-related traumatic events.

Unintended Consequence

Met. The chlordiazepoxide prescribed by the ship's medical officer from 15 January 1971, and continued with other sedatives until 1979, was given in place of psychological treatment while the veteran was returned to duty with the men who had assaulted him. The sedation suppressed his ability to process the events, and he became dependent on sedatives and alcohol. This is an unintended consequence of treatment provided by the Commonwealth during his service.

Inability to Attain Appropriate Medical Management

MET. From the onset of the disorder on 12 January 1971 the veteran was aboard a ship on warlike service and then on passage home, with no access to a psychiatrist, a psychologist or any confidential way to report the assaults. He was treated only with sedation and kept on watchkeeping duties alongside the perpetrators, and the disorder worsened by 21 January 1971. On arrival in Sydney he was sent on leave without referral, and his first psychiatric assessment did not occur until 15 March 1973, more than two years later. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the operational conditions at sea and the absence of any referral pathway for a 15-year-old junior sailor amount to an inability to obtain appropriate clinical management, and it contributed to the persistence and progression of the disorder.

5. Please provide a Health Summary and a medication / prescribing history.

See attached report.

References

1. 11 Feb 1970, Entry medical examination, Navy recruiting medical officer
2. 14 Dec 1970, Joining medical examination, Ship's medical officer
3. 23 Dec 1970, Sick bay treatment record, Ship's medical officer
4. 10 Jan 1971, Ship's log and sick bay register, Fast troop transport, Vung Tau anchorage
5. 11 Jan 1971, Signal notifying next of kin casualty, Army casualty section
6. 15 Jan 1971, Sick bay consultation record, Ship's medical officer
7. 21 Jan 1971, Sick bay consultation record, Ship's medical officer
8. 15 Mar 1973, Psychiatric assessment, Naval psychiatrist
9. 18 Jun 2024, Psychiatric assessment and report, Consultant psychiatrist
10. Statement of Principles concerning Acute Stress Disorder (Balance of Probabilities) No. 96 of 2022, Repatriation Medical Authority
11. Statement of Principles concerning Acute Stress Disorder (Reasonable Hypothesis) No. 95 of 2022, Repatriation Medical Authority