Chronic Insomnia Disorder — DVA claim example

Diagnostic Assessment — Chronic Insomnia Disorder

Example 1 of 1 · fictitious patient (Veteran A)

Diagnostic Assessment

Chronic Insomnia Disorder

BOP Code: 38 of 2019 (Chronic Insomnia Disorder)
RH Code: 37 of 2019 (Chronic Insomnia Disorder)

ADF History

Veteran A, date of birth 22 May 1969, Australian Army, Medical Assistant (Sergeant), enlisted 15 February 1990, medically discharged 30 June 2014. Operational service: East Timor, 20 September 1999 to 18 February 2000 (warlike); Afghanistan, 08 February 2010 to 02 July 2010 (warlike), ending in aeromedical evacuation after an improvised explosive device strike.

Occupational History

As an Army medical assistant the veteran provided first aid and emergency treatment in the field, travelled in protected vehicles on patrols and convoys, and treated and evacuated casualties of blast, gunshot and vehicle trauma. The role carries repeated exposure to death, critically injured casualties and human remains, as well as blast and noise exposure, malaria-endemic environments and the antimalarial medications used to prevent and treat malaria.

Medical assistants work shift and on-call rosters, including overnight duty in health centres and field hospitals, with disrupted and fragmented sleep. Serious physical injury is a recognised hazard of the trade, and members who are injured often undergo long periods of medical rehabilitation away from their unit and support networks.

History

Veteran A, an Army medical assistant, sustained life-threatening pelvic and right lower limb fractures, a concussion and blast ear injuries when her vehicle struck an improvised explosive device in Afghanistan on 02 July 2010, and developed posttraumatic stress disorder. During a prolonged rehabilitation complicated by septic shock, a further concussion, relapsing vivax malaria and a pregnancy, she developed chronic insomnia disorder in October 2011, which worsened in March 2012.

Timeline

• 12 Mar 2009 — At a gynaecology review the veteran, aged 39, reported irregular menstrual cycles, night sweats and hot flushes over the preceding four months. The serum FSH was 18 IU/L on day 3 of the cycle. The gynaecologist recorded that she had entered the menopausal transition. Sleep was recorded as normal apart from occasional waking with sweats. "perimenopausal, irregular cycles, hot flushes"
• 02 Jul 2010 — During warlike service in Uruzgan Province, Afghanistan, the protected vehicle in which the veteran was travelling struck an improvised explosive device. The driver was killed in front of her. She lost consciousness briefly and sustained an unstable pelvic ring fracture with haemorrhage requiring massive transfusion, open fractures of the right tibia and fibula and bilateral tympanic membrane perforations. She was aeromedically evacuated to Australia and spent eleven days in intensive care. "IED strike, pelvic fracture, transfused"
• 05 Dec 2010 — A consultant psychiatrist diagnosed posttraumatic stress disorder related to the blast and the death of the driver, with nightmares, hypervigilance and avoidance. She disclosed physical and sexual abuse by her stepfather between the ages of 7 and 13. Sertraline 50 mg daily was commenced and increased to 100 mg in January 2011. An audiologist confirmed bilateral constant tinnitus since the blast. Controlled-release oxycodone 20 mg twice daily continued for persistent pelvic and leg pain. She was mobilising only in a wheelchair. "PTSD, sertraline commenced, constant tinnitus"
• 14 Jun 2011 — The veteran was admitted to intensive care with septic shock from Staphylococcus aureus osteomyelitis of the right tibia around the fixation hardware. She required noradrenaline for four days, the hardware was removed and she received six weeks of intravenous antibiotics followed by daily wound care. Two months earlier, on 20 April 2011, she had fallen during a wheelchair transfer at the rehabilitation unit, struck her head and lost consciousness for two minutes, and concussion was diagnosed. "septic shock, tibial osteomyelitis, ICU"
• 25 Aug 2011 — The veteran presented with fevers and rigors, and a thick blood film showed Plasmodium vivax malaria, a relapse of infection acquired in Afghanistan for which eradication therapy had been deferred during her intensive care admission. She was 7 weeks pregnant, so primaquine was contraindicated. An infectious diseases physician treated her with mefloquine, followed by weekly mefloquine suppression until delivery. Metoclopramide 10 mg three times daily was started on 01 September 2011 for hyperemesis. "vivax relapse, mefloquine, pregnant 7/40"
• 06 Sep 2011 — At the rehabilitation unit the veteran witnessed a fellow wounded soldier fall from a balcony. He sustained critical head injuries and she performed cardiopulmonary resuscitation until paramedics arrived. Her psychologist recorded a marked increase in intrusive memories of the 2010 blast and that she felt isolated, living 900 kilometres from her unit and friends, and distressed at being told medical discharge was likely. "witnessed critical injury, performed CPR"
• 01 Nov 2011 — At the garrison health centre the veteran reported two weeks of difficulty falling asleep, waking three to four times a night and being unable to return to sleep after 3 am, on every night, despite a quiet single room and adequate time in bed. She reported restlessness in her legs at night since starting metoclopramide. She was 16 weeks pregnant. Insomnia Severity Index 17. She was referred for cognitive behavioural therapy for insomnia. "initial and maintenance insomnia, ISI 17"
• 23 Jan 2012 — A consultant psychiatrist confirmed chronic insomnia disorder under DSM-5 criteria: sleep difficulty on every night since mid-October 2011, more than three months' duration, with daytime fatigue, poor concentration and impaired functioning, despite adequate opportunity for sleep. Sleep diary showed sleep onset latency of 90 minutes and total sleep of four hours. Overnight oximetry excluded a breathing-related sleep disorder. A second vivax relapse on 18 January 2012 had been treated with mefloquine. "chronic insomnia disorder, DSM-5 confirmed"
• 12 Mar 2012 — At 35 weeks' gestation the veteran reported marked worsening, sleeping two to three hours a night with nightly panic on waking. Insomnia Severity Index had risen from 17 to 25. Metoclopramide had been increased to four times daily on 20 February 2012 with worse night-time restlessness. She had received written notice on 15 February 2012 that her medical discharge was proceeding. The psychiatrist recorded clinical worsening and arranged urgent review. "worsening insomnia, ISI 25"

Symptoms

At onset the veteran had difficulty initiating sleep, repeated night-time awakenings with difficulty returning to sleep and early-morning waking after 3 am, on every night, despite adequate opportunity for sleep. She had daytime fatigue, irritability, poor concentration and tearfulness, and was unable to engage fully with her rehabilitation programme.

After onset the sleep difficulty persisted beyond three months and worsened markedly in late pregnancy, with total sleep of two to three hours and nocturnal panic. She now reports persisting difficulty initiating and maintaining sleep on most nights, daytime exhaustion, reliance on a structured sleep routine and impaired concentration that limits her capacity for work and study.

Imaging

• 02 Jul 2010 — CT head, chest, abdomen and pelvis (trauma series): "No intracranial haemorrhage. Unstable vertical shear fracture of the pelvic ring with pelvic haematoma. Open comminuted fractures of the right tibia and fibula."
• 20 Apr 2011 — CT head: "Small right parietal scalp haematoma. No intracranial haemorrhage or skull fracture."
• 14 Jun 2011 — MRI right tibia: "Osteomyelitis of the mid tibial shaft surrounding the intramedullary nail, with a 3 cm subperiosteal collection."

Onset Date

The most likely date of onset of this condition is 18 Oct 2011.

At that date the veteran was a serving Army sergeant, medically held at a rehabilitation unit in Australia while recovering from the injuries she sustained on warlike service in Afghanistan. She was 14 weeks pregnant, mobilising in a wheelchair, taking sertraline, controlled-release oxycodone, metoclopramide and weekly mefloquine, and receiving daily wound care for tibial osteomyelitis. From that night she had difficulty falling asleep, woke repeatedly and could not return to sleep after 3 am.

This date is appropriate because a rehabilitation psychology review on 30 September 2011 recorded that she was sleeping about seven hours a night with her nightmares settling, and she first presented to the garrison health centre on 01 November 2011, reporting two weeks of nightly sleep difficulty. The sleep difficulty persisted for more than three months, and the psychiatrist confirmed on 23 January 2012 that it had been present since mid-October 2011. The date falls within continuous full-time service.

For the one-year factors, the year before onset runs from 18 Oct 2010 to 18 Oct 2011; within it she had posttraumatic stress disorder under ongoing psychiatric management, concussion on 20 April 2011, septic shock on 14 June 2011, the witnessed critical injury and resuscitation on 06 September 2011, ongoing social isolation and work concerns, and a severe, chronic medical condition. For the inability to exceed three METs, the year before onset was spent in a wheelchair or walking frame, and physiotherapy recorded a maximum capacity of about 2 METs. For the three-month factors, the three months before onset run from 18 Jul 2011 to 18 Oct 2011, during which she had continuous pelvic and leg pain and constant tinnitus. The 5 years before onset run from 18 Oct 2006 to 18 Oct 2011 and include the menopausal transition documented from 12 March 2009. The 2 months before onset run from 18 Aug 2011 to 18 Oct 2011 and include mefloquine from 25 August 2011. The 30 days before onset run from 18 Sep 2011 to 18 Oct 2011, during which she took sertraline, oxycodone and metoclopramide daily, each for well over seven continuous days. She was pregnant on 18 Oct 2011.

For the worsening factors, the documented worsening was on 12 Mar 2012. The year before it runs from 12 Mar 2011 to 12 Mar 2012 and contains the concussion, septic shock, witnessed critical injury, the notice of medical discharge on 15 February 2012 and continuing posttraumatic stress disorder. The three months before it run from 12 Dec 2011 to 12 Mar 2012, with continuing pain and tinnitus. The 2 months before it run from 12 Jan 2012 to 12 Mar 2012 and include mefloquine treatment for the relapse of 18 January 2012 and weekly suppression. The 30 days before it run from 11 Feb 2012 to 12 Mar 2012, during which sertraline, oxycodone and metoclopramide continued. She remained pregnant and unable to exceed three METs.

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

The formal diagnosis is Chronic Insomnia Disorder (ICD-10-AM F51.0), under the Statements of Principles concerning chronic insomnia disorder, Balance of Probabilities No. 38 of 2019 and Reasonable Hypothesis No. 37 of 2019.

Chronic insomnia disorder is a persistent dissatisfaction with the quantity or quality of sleep, with difficulty initiating sleep, maintaining sleep or early-morning waking, occurring at least three nights a week for at least three months despite adequate opportunity for sleep. It causes clinically significant distress or impairment in daytime functioning, including fatigue, poor concentration, irritability and low mood. It commonly arises in the setting of psychological trauma, mental health disorders, chronic pain, serious physical illness and medications that disturb sleep, and once established is maintained by conditioned arousal and maladaptive sleep behaviours.

The diagnosis followed the blast injuries and posttraumatic stress disorder of 2010 and a complicated rehabilitation through 2011. It began on 18 October 2011, was confirmed by a psychiatrist on 23 January 2012 and worsened in March 2012.

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

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

18 October 2011.

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

01 November 2011.

When was the condition confirmed / formally diagnosed?

23 January 2012.

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

17 June 2025.

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

The diagnosis was confirmed by a consultant psychiatrist on 23 January 2012 against the DSM-5 criteria set out in the Statement of Principles. The veteran had a predominant complaint of dissatisfaction with sleep quantity and quality, with difficulty initiating sleep, difficulty maintaining sleep and early-morning waking; the difficulty occurred on every night, well above the threshold of three nights a week, and had been present for more than three months since 18 October 2011. It caused clinically significant fatigue, poor concentration and impaired participation in rehabilitation.

The sleep difficulty occurred despite a quiet single room and adequate time in bed. Overnight oximetry excluded a breathing-related sleep disorder, there was no circadian rhythm disorder on sleep diary and no parasomnia, so the difficulty was not better explained by another sleep-wake disorder. The Insomnia Severity Index of 17 at presentation, rising to 25 at the worsening on 12 March 2012, and a sleep diary showing a sleep onset latency of 90 minutes and four hours of total sleep, support the diagnosis and the documented worsening.

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 18 October 2011, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service, including the veteran's period of rehabilitation in Australia. The Reasonable Hypothesis instrument applies to her warlike service in Afghanistan in 2010, where the blast injuries, the concussion, the posttraumatic stress disorder, the tinnitus and the malaria infection that later relapsed all arose, and to the consequences of those injuries through her rehabilitation.

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.

Balance of Probabilities — Statement of Principles concerning Chronic Insomnia Disorder, No. 38 of 2019

Causative factors

Factor 8(1): having a clinically significant disorder of mental health as specified within the one year before the clinical onset of chronic insomnia disorder; — MET

- A consultant psychiatrist diagnosed posttraumatic stress disorder on 05 December 2010, with monthly psychiatric review and daily sertraline, so it was of sufficient severity to warrant ongoing management. Posttraumatic stress disorder is on the specified list. It was present throughout the year before onset, from 18 October 2010 to 18 October 2011.

Factor 8(2): experiencing a category 1A stressor within the one year before the clinical onset of chronic insomnia disorder; — MET

- On 14 June 2011 the veteran experienced a life-threatening event when she developed septic shock requiring noradrenaline and intensive care. The sepsis arose in the fixation hardware inserted to repair fractures sustained in service, and it occurred within the year before onset on 18 October 2011.

Factor 8(3): experiencing a category 1B stressor within the one year before the clinical onset of chronic insomnia disorder; — MET

- On 06 September 2011, at the Defence rehabilitation unit, the veteran was an eyewitness to a fellow soldier being critically injured in a fall and participated in the care of that critically injured casualty by performing cardiopulmonary resuscitation. This was six weeks before onset.

Factor 8(4): experiencing a category 2 stressor within the one year before the clinical onset of chronic insomnia disorder; — MET

- Throughout 2011 the veteran was socially isolated and unable to maintain friendships because of her disability and her posting to a rehabilitation unit 900 kilometres from her unit, and she had ongoing concerns in the work environment after being told in mid-2011 that medical discharge was likely. Her psychologist recorded ongoing distress about both in the year before onset.

Factor 8(5): experiencing severe childhood abuse before the clinical onset of chronic insomnia disorder; — MET

- At her psychiatric assessment on 05 December 2010 the veteran disclosed serious physical and sexual harm perpetrated by her stepfather between the ages of 7 and 13, well before the onset of the insomnia in 2011.

Factor 8(6): having a medical illness or injury, which is life-threatening or which results in serious physical or cognitive disability, within the one year before the clinical onset of chronic insomnia disorder; — MET

- Septic shock from tibial osteomyelitis on 14 June 2011 was a life-threatening medical illness, and the service injuries of 2010 resulted in serious physical disability that persisted throughout the year before onset, leaving her dependent on a wheelchair. Both fall within the year from 18 October 2010 to 18 October 2011.

Factor 8(7): having a severe, chronic medical condition within the one year before the clinical onset of chronic insomnia disorder; — MET

- From June 2011 the veteran had chronic osteomyelitis of the right tibia with an unstable healed pelvic fracture. The condition substantially impacted on her occupational and social functioning, required daily wound care, daily drug therapy and physiotherapy under registered health practitioners, and is of a type that is rarely cured completely. It was present in the year before onset.

Factor 8(8): having persistent pain for at least the three months before the clinical onset of chronic insomnia disorder; — MET

- The veteran had continuous pelvic and right leg pain from the service injuries from July 2010, requiring controlled-release oxycodone, which interfered with her rehabilitation and daily activities. The pain was present throughout the three months before onset, from 18 July 2011 to 18 October 2011.

Factor 8(9): having tinnitus for at least the three months before the clinical onset of chronic insomnia disorder; — MET

- Bilateral constant tinnitus followed the blast and tympanic membrane perforations of 02 July 2010 and was confirmed by an audiologist on 05 December 2010. It was present continuously through the three months before onset.

Factor 8(10): being pregnant at the time of the clinical onset of chronic insomnia disorder; — MET

- The veteran's last menstrual period was 08 July 2011 and pregnancy was confirmed on 12 August 2011. She was 14 weeks pregnant on 18 October 2011, the date of onset, while serving and medically held for her service injuries.

Factor 8(11): being treated with a drug or a drug from a class of drugs from the specified list of drugs, for a continuous period of at least seven days before the clinical onset of chronic insomnia disorder, where the last dose of the drug was received within the 30 days before the clinical onset of chronic insomnia disorder; — MET

- The veteran took sertraline, a selective serotonin reuptake inhibitor, continuously from 05 December 2010 for service-related posttraumatic stress disorder, and controlled-release oxycodone, an opioid analgesic, continuously for pain from her service injuries. Both are on the specified list, both were taken for far longer than seven continuous days and both were taken daily up to and including 18 October 2011.

Factor 8(12): being treated with a drug for a continuous period of at least seven days before the clinical onset of chronic insomnia disorder, where: (a) the involved drug is capable of producing a prominent and severe disturbance in sleep; and (b) the drug is associated in the individual with the development of insomnia symptoms during drug therapy; and (c) the last dose was received within the 30 days before the clinical onset of chronic insomnia disorder; — MET

- Metoclopramide 10 mg three times daily was prescribed continuously from 01 September 2011 for hyperemesis. Metoclopramide is capable of producing a prominent and severe disturbance in sleep through akathisia, and the veteran developed night-time restlessness and sleep difficulty during therapy, recorded on 01 November 2011. She was still taking it daily on 18 October 2011.

Factor 8(13): being treated with mefloquine within the two months before the clinical onset of chronic insomnia disorder; — MET

- An infectious diseases physician treated the veteran with mefloquine on 25 August 2011 for relapsing vivax malaria acquired in service, then continued weekly mefloquine suppression. This falls within the two months before onset, from 18 August 2011 to 18 October 2011.

Worsening factors

Factor 8(14): having a clinically significant disorder of mental health as specified within the one year before the clinical worsening of chronic insomnia disorder; — MET

- Posttraumatic stress disorder under monthly psychiatric management continued throughout the year before the documented worsening on 12 March 2012, when the Insomnia Severity Index rose from 17 to 25.

Factor 8(15): experiencing a category 1A stressor within the one year before the clinical worsening of chronic insomnia disorder; — MET

- The life-threatening septic shock of 14 June 2011 fell within the year before the worsening, which runs from 12 March 2011 to 12 March 2012.

Factor 8(16): experiencing a category 1B stressor within the one year before the clinical worsening of chronic insomnia disorder; — MET

- The witnessed critical injury and resuscitation on 06 September 2011 fell within the year before the worsening on 12 March 2012.

Factor 8(17): experiencing a category 2 stressor within the one year before the clinical worsening of chronic insomnia disorder; — MET

- On 15 February 2012 the veteran received written notice that her medical discharge was proceeding, adding to the ongoing work concerns and social isolation recorded through the year before the worsening.

Factor 8(18): having a medical illness or injury, which is life-threatening or which results in serious physical or cognitive disability, within the one year before the clinical worsening of chronic insomnia disorder; — MET

- The septic shock of 14 June 2011 and the persisting serious physical disability from the service injuries both fell within the year before the worsening on 12 March 2012.

Factor 8(19): having a severe, chronic medical condition within the one year before the clinical worsening of chronic insomnia disorder; — MET

- Chronic tibial osteomyelitis requiring daily wound care and drug therapy continued through the year before the worsening.

Factor 8(20): having persistent pain for at least the three months before the clinical worsening of chronic insomnia disorder; — MET

- Continuous pelvic and leg pain requiring oxycodone persisted throughout the three months before the worsening, from 12 December 2011 to 12 March 2012.

Factor 8(21): having tinnitus for at least the three months before the clinical worsening of chronic insomnia disorder; — MET

- Constant bilateral tinnitus persisted throughout the three months before the worsening and was recorded as keeping her awake at night.

Factor 8(22): being pregnant at the time of the clinical worsening of chronic insomnia disorder; — MET

- The veteran was 35 weeks pregnant on 12 March 2012 when the worsening was documented.

Factor 8(23): being treated with a drug or a drug from a class of drugs from the specified list of drugs, for a continuous period of at least seven days before the clinical worsening of chronic insomnia disorder, where the last dose of the drug was received within the 30 days before the clinical worsening of chronic insomnia disorder; — MET

- Sertraline and controlled-release oxycodone, both on the specified list, were taken continuously and daily throughout the 30 days before the worsening, from 11 February 2012 to 12 March 2012.

Factor 8(24): being treated with a drug for a continuous period of at least seven days before the clinical worsening of chronic insomnia disorder, where: (a) the involved drug is capable of producing a prominent and severe disturbance in sleep; and (b) the drug is associated in the individual with the worsening of insomnia symptoms during drug therapy; and (c) the last dose was received within the 30 days before the clinical worsening of chronic insomnia disorder; — MET

- Metoclopramide continued daily and was increased to four times daily on 20 February 2012, after which night-time restlessness and the insomnia worsened, as recorded on 12 March 2012. She took it up to the date of the worsening.

Factor 8(25): being treated with mefloquine within the two months before the clinical worsening of chronic insomnia disorder; — MET

- Mefloquine was given for the vivax relapse of 18 January 2012 and weekly suppression continued, within the two months before the worsening, from 12 January 2012 to 12 March 2012.

Factor 8(26): inability to obtain appropriate clinical management for chronic insomnia disorder. — MET

- The veteran was referred for cognitive behavioural therapy for insomnia on 01 November 2011, but no provider was available at the rehabilitation unit and her first session did not take place until 20 June 2012. Hypnotic medication was withheld because of pregnancy, and her insomnia went without effective treatment for over seven months and worsened. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

Reasonable Hypothesis — Statement of Principles concerning Chronic Insomnia Disorder, No. 37 of 2019

Causative factors

Factor 8(1): having a clinically significant disorder of mental health as specified within the one year before the clinical onset of chronic insomnia disorder; — MET

- Posttraumatic stress disorder arising from the improvised explosive device strike and the death of the driver on warlike service in Afghanistan on 02 July 2010 was diagnosed on 05 December 2010 and was under ongoing management throughout the year before onset.

Factor 8(2): experiencing a category 1A stressor within the one year before the clinical onset of chronic insomnia disorder; — MET

- The life-threatening septic shock of 14 June 2011 arose in hardware used to fix the open tibial fracture sustained on warlike service in Afghanistan, and occurred within the year before onset.

Factor 8(3): experiencing a category 1B stressor within the one year before the clinical onset of chronic insomnia disorder; — MET

- On 06 September 2011, while medically held for her warlike service injuries, the veteran witnessed a fellow wounded soldier's critical injury and performed resuscitation. This revived the trauma of the 2010 blast in Afghanistan and occurred within the year before onset.

Factor 8(4): experiencing a category 2 stressor within the one year before the clinical onset of chronic insomnia disorder; — MET

- The social isolation from disability and the work concerns about likely medical discharge, recorded through 2011, flowed directly from the injuries sustained on warlike service in Afghanistan and fell within the year before onset.

Factor 8(5): experiencing severe childhood abuse before the clinical onset of chronic insomnia disorder; — MET

- Serious physical and sexual abuse by her stepfather between the ages of 7 and 13 was disclosed at the psychiatric assessment of 05 December 2010 that followed her warlike service, and preceded the onset of the insomnia.

Factor 8(6): having a medical illness or injury, which is life-threatening or which results in serious physical or cognitive disability, within the one year before the clinical onset of chronic insomnia disorder; — MET

- The septic shock of 14 June 2011 was life-threatening, and the pelvic and tibial injuries sustained on warlike service in Afghanistan resulted in serious physical disability throughout the year before onset.

Factor 8(7): having a severe, chronic medical condition within the one year before the clinical onset of chronic insomnia disorder; — MET

- Chronic tibial osteomyelitis, a complication of the open fracture sustained on warlike service, required daily wound care, drug therapy and physiotherapy and substantially impaired her functioning through the year before onset.

Factor 8(8): having persistent pain for at least the three months before the clinical onset of chronic insomnia disorder; — MET

- Continuous pain from the pelvic and tibial fractures sustained on warlike service on 02 July 2010 was present throughout the three months before onset, from 18 July 2011 to 18 October 2011.

Factor 8(9): having tinnitus for at least the three months before the clinical onset of chronic insomnia disorder; — MET

- Constant bilateral tinnitus followed the blast on warlike service in Afghanistan on 02 July 2010 and was present throughout the three months before onset.

Factor 8(10): having concussion or moderate to severe traumatic brain injury within the one year before the clinical onset of chronic insomnia disorder; — MET

- On 20 April 2011 the veteran fell during a wheelchair transfer that was necessary because of her warlike service injuries, struck her head and lost consciousness for two minutes. Concussion was diagnosed, with a normal CT head. This was within the year before onset on 18 October 2011.

Factor 8(11): being in the menopausal transition within the five years before the clinical onset of chronic insomnia disorder; — MET

- A gynaecologist documented the menopausal transition on 12 March 2009, with irregular cycles, hot flushes and a raised FSH, and her symptoms continued during her warlike service in Afghanistan in 2010 and afterwards. This falls within the five years before onset, from 18 October 2006 to 18 October 2011.

Factor 8(12): being pregnant at the time of the clinical onset of chronic insomnia disorder; — MET

- The veteran was 14 weeks pregnant on 18 October 2011, while still medically held for the injuries of her warlike service in Afghanistan.

Factor 8(13): inability to undertake any physical activity greater than three METs for at least the one year before the clinical onset of chronic insomnia disorder; — MET

- From the blast on warlike service on 02 July 2010 the veteran was confined to a wheelchair and later a walking frame. Physiotherapy records show she could not exceed about 2 METs at any time in the year before onset, from 18 October 2010 to 18 October 2011.

Factor 8(14): being treated with a drug or a drug from a class of drugs from the specified list of drugs, for a continuous period of at least seven days before the clinical onset of chronic insomnia disorder, where the last dose of the drug was received within the 30 days before the clinical onset of chronic insomnia disorder; — MET

- Sertraline for posttraumatic stress disorder and controlled-release oxycodone for pain, both arising from warlike service in Afghanistan, were taken continuously for over ten months and daily up to the onset on 18 October 2011.

Factor 8(15): being treated with a drug for a continuous period of at least seven days before the clinical onset of chronic insomnia disorder, where: (a) the involved drug is capable of producing a prominent and severe disturbance in sleep; and (b) the drug is associated in the individual with the development of insomnia symptoms during drug therapy; and (c) the last dose was received within the 30 days before the clinical onset of chronic insomnia disorder; — MET

- Metoclopramide was taken continuously from 01 September 2011, alongside mefloquine for malaria acquired on warlike service, and the veteran developed night-time restlessness and insomnia during therapy. She was taking it daily at onset.

Factor 8(16): being treated with mefloquine within the two months before the clinical onset of chronic insomnia disorder; — MET

- Mefloquine was given on 25 August 2011 and weekly thereafter for relapsing Plasmodium vivax malaria acquired on warlike service in Uruzgan Province, Afghanistan, within the two months before onset.

Worsening factors

Factor 8(17): having a clinically significant disorder of mental health as specified within the one year before the clinical worsening of chronic insomnia disorder; — MET

- Posttraumatic stress disorder from warlike service in Afghanistan remained under active management throughout the year before the worsening on 12 March 2012.

Factor 8(18): experiencing a category 1A stressor within the one year before the clinical worsening of chronic insomnia disorder; — MET

- The septic shock of 14 June 2011, a complication of the warlike service fractures, fell within the year before the worsening.

Factor 8(19): experiencing a category 1B stressor within the one year before the clinical worsening of chronic insomnia disorder; — MET

- The witnessed critical injury and resuscitation on 06 September 2011, during rehabilitation for warlike service injuries, fell within the year before the worsening.

Factor 8(20): experiencing a category 2 stressor within the one year before the clinical worsening of chronic insomnia disorder; — MET

- Notice of medical discharge on 15 February 2012, a direct result of the injuries sustained on warlike service, and ongoing social isolation fell within the year before the worsening.

Factor 8(21): having a medical illness or injury, which is life-threatening or which results in serious physical or cognitive disability, within the one year before the clinical worsening of chronic insomnia disorder; — MET

- The septic shock of June 2011 and the serious physical disability from the warlike service injuries were present within the year before the worsening.

Factor 8(22): having a severe, chronic medical condition within the one year before the clinical worsening of chronic insomnia disorder; — MET

- Chronic tibial osteomyelitis complicating the warlike service fracture required daily management throughout the year before the worsening.

Factor 8(23): having persistent pain for at least the three months before the clinical worsening of chronic insomnia disorder; — MET

- Continuous pain from the warlike service fractures persisted throughout the three months before the worsening, from 12 December 2011 to 12 March 2012.

Factor 8(24): having tinnitus for at least the three months before the clinical worsening of chronic insomnia disorder; — MET

- Blast-related tinnitus from warlike service persisted throughout the three months before the worsening.

Factor 8(25): having concussion or moderate to severe traumatic brain injury within the one year before the clinical worsening of chronic insomnia disorder; — MET

- The concussion of 20 April 2011, sustained in a fall caused by her warlike service injuries, fell within the year before the worsening, from 12 March 2011 to 12 March 2012.

Factor 8(26): being in the menopausal transition within the five years before the clinical worsening of chronic insomnia disorder; — MET

- The menopausal transition documented from 12 March 2009, continuing through her warlike service, fell within the five years before the worsening.

Factor 8(27): being pregnant at the time of the clinical worsening of chronic insomnia disorder; — MET

- The veteran was 35 weeks pregnant on 12 March 2012, still medically held for her warlike service injuries.

Factor 8(28): inability to undertake any physical activity greater than three METs for at least the one year before the clinical worsening of chronic insomnia disorder; — MET

- She remained unable to exceed about 2 METs throughout the year before the worsening because of the pelvic and tibial injuries from warlike service.

Factor 8(29): being treated with a drug or a drug from a class of drugs from the specified list of drugs, for a continuous period of at least seven days before the clinical worsening of chronic insomnia disorder, where the last dose of the drug was received within the 30 days before the clinical worsening of chronic insomnia disorder; — MET

- Sertraline and oxycodone, prescribed for conditions arising from warlike service, were taken daily throughout the 30 days before the worsening.

Factor 8(30): being treated with a drug for a continuous period of at least seven days before the clinical worsening of chronic insomnia disorder, where: (a) the involved drug is capable of producing a prominent and severe disturbance in sleep; and (b) the drug is associated in the individual with the worsening of insomnia symptoms during drug therapy; and (c) the last dose was received within the 30 days before the clinical worsening of chronic insomnia disorder; — MET

- Metoclopramide was increased on 20 February 2012 and taken daily to the worsening, with documented worsening of night-time restlessness and insomnia.

Factor 8(31): being treated with mefloquine within the two months before the clinical worsening of chronic insomnia disorder; — MET

- Mefloquine for the second relapse of vivax malaria acquired on warlike service, on 18 January 2012, and weekly suppression fell within the two months before the worsening.

Factor 8(32): inability to obtain appropriate clinical management for chronic insomnia disorder. — MET

- While medically held for her warlike service injuries the veteran could not obtain cognitive behavioural therapy for insomnia for more than seven months after referral, and her insomnia worsened in that period.

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

Sequelae

The chronic insomnia disorder is a sequela of the veteran's accepted conditions: posttraumatic stress disorder, chronic pain from the pelvic and right tibial fractures, chronic tibial osteomyelitis and blast-related tinnitus, all arising from the improvised explosive device strike on warlike service in Afghanistan on 02 July 2010, together with the sertraline and oxycodone prescribed to treat them.

Unintended Consequence

Met. The insomnia is in part an unintended consequence of medical treatment provided by or paid for by the Commonwealth while the veteran was serving: mefloquine for malaria acquired on deployment, metoclopramide given alongside it, and sertraline and oxycodone for her service-related posttraumatic stress disorder and pain (section 6A of the DRCA and the equivalent provisions of the MRCA).

Inability to Attain Appropriate Medical Management

MET. The veteran was referred for cognitive behavioural therapy for insomnia, the first-line treatment, on 01 November 2011, but no provider was available to the rehabilitation unit and she did not begin treatment until 20 June 2012. Hypnotic medication was not an option during pregnancy. Her insomnia went untreated for over seven months and worsened, with the Insomnia Severity Index rising from 17 to 25. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the unavailability of the indicated treatment within a reasonable time, in circumstances beyond her control, amounts to an inability to obtain appropriate clinical management.

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

See attached report.

References

1. 12 Mar 2009, Gynaecology consultation and hormone profile, Gynaecologist
2. 02 Jul 2010, Trauma admission and CT trauma series, Role 3 hospital, Afghanistan
3. 05 Dec 2010, Psychiatric assessment, Consultant psychiatrist
4. 05 Dec 2010, Audiology report, Audiologist
5. 20 Apr 2011, Emergency department record and CT head, Emergency physician
6. 14 Jun 2011, Intensive care discharge summary and MRI right tibia, Intensivist and orthopaedic surgeon
7. 25 Aug 2011, Infectious diseases consultation, Infectious diseases physician
8. 06 Sep 2011, Psychology progress note, Rehabilitation psychologist
9. 30 Sep 2011, Psychology review, Rehabilitation psychologist
10. 01 Nov 2011, Outpatient health record, Medical Officer, Garrison health centre
11. 23 Jan 2012, Psychiatric review and sleep diary, Consultant psychiatrist
12. 15 Feb 2012, Medical employment classification notice, Defence
13. 12 Mar 2012, Psychiatric review, Consultant psychiatrist
14. 20 Jun 2012, Cognitive behavioural therapy for insomnia, initial session, Clinical psychologist
15. Statement of Principles concerning Chronic Insomnia Disorder (Balance of Probabilities) No. 38 of 2019, Repatriation Medical Authority
16. Statement of Principles concerning Chronic Insomnia Disorder (Reasonable Hypothesis) No. 37 of 2019, Repatriation Medical Authority