Mental Health - Compensation Impairment Assessment (CIA) - Anxiety and Depression — DVA claim example

Compensation Impairment Assessment (CIA) — Mental Health - Compensation Impairment Assessment (CIA) - Anxiety and Depression

Example 1 of 1 · fictitious patient (Veteran V)

Compensation Impairment Assessment (CIA)

Mental Health - Compensation Impairment Assessment (CIA) - Anxiety and Depression

Psychiatric Assessment Report prepared for a DVA Compensation Impairment Assessment (GARP M Chapter 4) — Generalised Anxiety Disorder, Adjustment Disorder, Major Depressive Disorder and Alcohol Use Disorder

MENTAL HEALTH ASSESSMENT

History

Developmental and Family History

The veteran a 52-year-old male, reports a childhood characterized by significant geographic instability due to his father's service in the Royal Australian Air Force (RAAF). He self-identifies as a "RAAF brat," a designation that carries implications for attachment patterns and adaptive mechanisms developed during formative years. The frequent relocations across Australia during his developmental period likely contributed to challenges in establishing sustained peer relationships and maintaining consistent educational progression.

The veteran completed his secondary education at a state high school, concluding his studies in Year 12 in 1987. Despite the disruptions inherent in multiple relocations, he describes his familial relationships during childhood as positive, particularly noting a good relationship with his father. This positive paternal relationship appears to have influenced his subsequent decision to pursue military service.

Educational and Occupational History

Following completion of secondary education, the veteran demonstrated vocational initiative by commencing an apprenticeship in electronics. His career trajectory included retail employment, which terminated due to business closure - a circumstance beyond his control. He subsequently continued his technical training as an electrical apprentice, eventually qualifying as an electrician within the local council infrastructure.

Of psychological significance is his initial unsuccessful attempt to enlist in the RAAF immediately post-secondary education. The rejection, attributed to inadequate mathematics scores preventing his desired technical pathway, represents an early narcissistic injury that may have contributed to later vulnerability factors. His father had separated from military service by this time, removing a potential protective mentoring influence.

Military Service History

The veteran successfully enlisted in the Royal Australian Air Force on 12 July 1990 at age 23, serving as an avionics technician (AVTECH) until his discharge on 26 July 1996. His initial military experience was reportedly positive, with particular satisfaction derived from working on F/A-18 Hornet aircraft systems. This initial period of adjustment suggests adequate premorbid functioning and capacity for military adaptation.

However, the veteran sustained a significant injury during trade training at the RAAF base, which impeded his professional progression and initiated a cascade of biopsychosocial stressors. The temporal confluence of physical injuries with psychosocial stressors, notably his parents' marital separation, created a complex stress matrix. His request for compassionate posting and leave to provide family support was denied, representing what he conceptualizes as "administrative violence" - a term suggesting perceived institutional betrayal and moral injury.

The concurrent presence of an undiagnosed pars interarticularis fracture during this period added an element of invalidation to his experience, as his physical suffering lacked official recognition. He sought support through the military chaplaincy service and was ultimately discharged on compassionate grounds, though this resolution came after significant psychological distress had crystallized.

Past Psychiatric History (Axis I)

Current Symptom Presentation

The veteran presents with a complex symptom constellation consistent with moderate to severe psychological distress across multiple domains:

Anxiety Symptoms (GAD-7 Score: 11 - Moderate; DASS21 Anxiety: 9 - Severe):

• Persistent feelings of nervousness, anxiety, and being on edge occurring more than half the days
• Difficulty controlling worry, with ruminative thought patterns
• Excessive worry about multiple life domains
• Psychomotor restlessness manifesting as inability to sit still
• Muscle tension and somatic hypervigilance
• Irritability and decreased frustration tolerance
• Catastrophic thinking patterns with fears of awful events occurring

Depressive Symptoms (DASS21 Depression: 9 - Moderate; K10 Score: 23 - High):

• Persistent low mood occurring on most days
• Anhedonia with inability to experience positive emotions
• Psychomotor retardation with difficulty initiating activities
• Feelings of hopelessness regarding the future
• Periodic feelings of worthlessness
• Emotional numbing and affective restriction
• Fatigue without apparent cause occurring frequently

Stress-Related Symptoms (DASS21 Stress: 10 - Moderate):

• Difficulty achieving relaxation states
• Tendency to over-react to situational stressors
• Intolerance of interruptions or delays
• Persistent feelings of nervous energy expenditure
• Dry mouth and other autonomic symptoms
• Physiological arousal including trembling and cardiac awareness

Social and Behavioral Manifestations:

• Marked social avoidance and withdrawal from interpersonal interactions
• Complete avoidance of social situations beyond essential requirements
• Significant difficulties with patience in interpersonal contexts
• Crowd avoidance suggesting possible agoraphobic features
• Short temper and decreased frustration tolerance
• Impatience as a predominant interpersonal characteristic
• Loss of interest in previously enjoyed recreational activities

Sleep and Substance Use:

• Chronic insomnia with both sleep initiation and maintenance difficulties
• Alcohol use disorder with consumption of 10 standard drinks nightly
• Use of alcohol as maladaptive coping mechanism for anxiety and sleep

Medication History

Current medications include:

• Statins for hyperlipidemia management
• Proton pump inhibitors for gastroesophageal reflux disease

The veteran was prescribed antidepressant medication approximately 4 years ago during a period of significant legal stressors, but has not maintained consistent psychiatric follow-up or medication compliance. The lack of structured mental health intervention represents a significant treatment gap.

Recommended addition: Meloxicam for comorbid pain management, which may have secondary benefits for mood stabilization through reduction of inflammatory processes.

Past Personality History (Axis II)

No evidence of premorbid personality disorder. Personality structure appears to have been within normal limits prior to military service, with subsequent characterological changes attributable to chronic psychiatric symptomatology rather than primary personality pathology.

Medical History (Axis III)

Based on comprehensive review of medical documentation, the following conditions have been diagnosed:

Musculoskeletal Conditions:

• Chronic lower back pain with L5/S1 spina bifida occulta
• Bilateral shoulder pathology with rotator cuff tendinopathy and labral tears
• Right hip labral tear with associated CAM lesion
• Right knee patellofemoral chondromalacia
• Right ankle chronic ATFL tear
• Cervical spondylosis with multilevel degenerative changes
• Thoracic spine disc protrusions (T4/5, T5/6)
• Lumbar spine disc bulges (L1/2, L4/5) with retrolisthesis
• Leg length discrepancy

Other Medical Conditions:

• Hypercholesterolemia
• Gastroesophageal reflux disease
• History of left epididymitis
• Benign vertebral hemangiomas (T8, L2, L5)
• Vision impairment requiring correction

Lifestyle Factors (Axis IV)

Alcohol Use

Severe alcohol use disorder with consumption of at least 10 standard drinks nightly. This level of consumption significantly exceeds safe drinking guidelines and meets criteria for severe alcohol use disorder with both physiological dependence and psychological reliance features.

Substance Use

Denies use of illicit substances.

Exercise

Currently sedentary with no regular exercise program, likely secondary to both physical limitations and motivational deficits associated with depression.

Diet

Poor nutritional intake with inadequate attention to dietary requirements.

Financial Status

Reports no current financial stressors, suggesting adequate economic resources and stability.

Social Functioning

Severe social withdrawal with avoidance of all non-essential social situations. This represents a marked departure from premorbid functioning and significantly impacts quality of life.

Domestic Relationships

The veteran reports that his relationship with his wife is currently stable and supportive. She serves as "his rock," providing essential emotional scaffolding. No current marital conflict or discord is reported, suggesting this relationship remains a protective factor despite his psychological difficulties.

Occupational Functioning

Currently employed as an electrician subcontracted to a defence contractor for deployable health systems. Maintains occupational functioning despite psychological symptoms, though efficiency and interpersonal aspects of work performance may be compromised.

Recreation

Continues to play golf but reports marked loss of interest in most previously enjoyed activities, consistent with anhedonic features of depression.

Global Assessment of Functioning (Axis V)

Current GAF: 60 - Moderate symptoms with moderate difficulty in social and occupational functioning.

MANAGEMENT

The veteran maintains contact with a general practitioner whom he sees opportunistically rather than for scheduled mental health management. He has no current structured mental health care plan. Previous antidepressant treatment 4 years ago was not followed by structured monitoring or optimization. This represents a significant gap in evidence-based treatment for his diagnosed conditions.

MENTAL STATE EXAMINATION

Appearance: Caucasian male appearing stated age, speaking with Australian accent
Posture: Normal, no psychomotor abnormalities observed
Attire: Casual dress appropriate to context
Grooming: Moderately poor self-care suggestive of decreased attention to hygiene
Hygiene: Suboptimal, consistent with depressive neglect
Attitude: Cooperative and engaged with assessment process
Rapport: Adequate therapeutic alliance established
Behavior: No abnormal movements or mannerisms observed
Mood: Subjectively reported as "anxious and low"
Speech: Normal rate, rhythm, volume, and prosody
Affect: Restricted range with anxious quality, mood-congruent
Thought Form: Linear and goal-directed
Thought Content: Preoccupation with service-related grievances, no psychotic features
Perception: No hallucinatory experiences reported or observed
Cognition: Grossly intact, formal testing not conducted
Insight: Good insight into psychological nature of difficulties
Judgment: Intact for daily decision-making

SUICIDE AND SELF-HARM ASSESSMENT

Historical Risk Factors:

• Previous suicidal ideation with preparatory behaviors 4 years ago secondary to legal stressors
• Had formulated plan and taken preparatory steps at that time
• No history of self-harm behaviors

Current Risk Assessment:

• Denies current suicidal ideation
• No current plan or intent
• Ongoing risk factor: Alcohol use disorder
• Protective factor: Supportive relationship with wife who serves as "his rock"

Risk Formulation: Currently LOW risk for suicide with historical elevation requiring ongoing monitoring

SCORING SUMMARY

K10: 23 (High psychological distress)
DASS21: Depression 9 (Moderate), Anxiety 9 (Severe), Stress 10 (Moderate)
GAD7: 11 (Moderate anxiety)
PCL-5: Not administered

DIAGNOSTIC FORMULATION

Primary Diagnoses (DSM-5-TR)

1. Generalized Anxiety Disorder (300.02) - 60% of impairment

The veteran meets full DSM-5-TR criteria for Generalized Anxiety Disorder:

Criterion A: Excessive anxiety and worry occurring more days than not for at least 6 months about multiple domains (work performance, social interactions, health, family relationships).

Criterion B: Difficulty controlling the worry, with ruminative patterns resistant to cognitive restructuring.

Criterion C: Associated symptoms present:

• Restlessness and feeling on edge (reported as frequent)
• Easy fatigability (endorsed "some of the time")
• Difficulty concentrating (impacts occupational function)
• Irritability (prominent feature affecting relationships)
• Muscle tension (somatic manifestation)
• Sleep disturbance (chronic insomnia)

Criterion D: Clinically significant distress with impairment in social and occupational functioning.

Criterion E: Not attributable to substance effects, though alcohol use represents maladaptive coping.

Criterion F: Not better explained by another mental disorder.

2. Major Depressive Disorder, Moderate, Single Episode (296.22) - 20% of impairment

Diagnostic criteria met:

• Depressed mood most of the day, nearly every day
• Markedly diminished interest in activities (anhedonia)
• Insomnia nearly every night
• Psychomotor retardation observed and reported
• Fatigue and loss of energy
• Feelings of worthlessness
• Diminished concentration ability
• Previous suicidal ideation (currently resolved)

Symptoms cause clinically significant distress and functional impairment.

3. Adjustment Disorder with Mixed Anxiety and Depressed Mood (309.28) - Historical

At time of discharge from ADF, met criteria for Adjustment Disorder:

• Emotional symptoms within 3 months of identifiable stressor (injury, parental separation, denied compassionate leave)
• Marked distress disproportionate to stressor severity
• Significant impairment in occupational functioning leading to discharge

This has evolved into the current discrete anxiety and depressive disorders.

4. Alcohol Use Disorder, Severe (303.90) - 20% of impairment

Meets multiple DSM-5-TR criteria:

• Alcohol taken in larger amounts than intended (10 drinks nightly)
• Persistent desire with unsuccessful attempts to reduce use
• Continued use despite psychological problems
• Tolerance evident
• Likely withdrawal symptoms masked by continuous consumption
• Use in physically hazardous situations probable
• Significant time spent obtaining and consuming alcohol

IMPAIRMENT ASSESSMENT

4.1 SUBJECTIVE DISTRESS

4.2 MANIFEST DISTRESS

Work colleagues have noted his distressed and anxious presentation. His wife is acutely aware of his psychological difficulties.

4.3 FUNCTIONAL EFFECTS

4.4 OCCUPATION

4.5 DOMESTIC SITUATION

4.6 SOCIAL INTERACTION

4.7 LEISURE ACTIVITIES

4.8 CURRENT THERAPY

OVERALL IMPAIRMENT CALCULATION

SCHEDULE OF QUESTIONS - DVA ASSESSMENT

1. For how long have you been treating the patient?

Initial comprehensive assessment conducted on 04 July 2019. Historical information obtained through detailed clinical interview and review of extensive military and medical documentation.

2. What is the claimant's psychiatric history?

2.1 Prior to service?

No evidence of psychiatric disorder prior to military service. Developmental history notable for multiple relocations but adequate adaptation. Successfully completed secondary education and vocational training. Initial rejection from RAAF represented disappointment but not psychiatric decompensation.

2.2 During service?

Development of adjustment disorder with mixed anxiety and depressed mood following confluence of physical injury at the RAAF base, parental separation, and perceived lack of institutional support. Sleep disturbance and alcohol use emerged as maladaptive coping strategies. Psychological distress sufficient to seek chaplaincy support and ultimately receive compassionate discharge.

2.3 After service?

Progressive evolution from adjustment disorder to discrete anxiety and depressive disorders. Severe social withdrawal developed over time. Alcohol use disorder established as chronic maladaptive coping mechanism. Episode of severe decompensation with suicidal ideation 4 years ago during legal stressors, followed by incomplete treatment engagement.

3. Full statement of events/incidents/occurrences believed to be origin of claimed psychiatric disorders

The primary precipitating events occurred during military service, specifically:

• Physical injury during avionics training at the RAAF base (1994-1995)
• Concurrent parental marital separation creating family crisis
• Denial of compassionate posting/leave request despite family emergency
• Experience of "administrative violence" - perceived institutional betrayal
• Undiagnosed pars interarticularis fracture causing invalidated suffering
• Multiple somatic injuries affecting back, hip, shoulders, knee, and ankle
• Cascading functional limitations impacting career progression

These events occurred within the context of high occupational demands and exposure to military cultural factors that may have inhibited help-seeking.

4. Details of corroborative evidence sought

4.1 Partner/Spouse

Wife aware of his psychological difficulties and serves as primary support. Formal corroborative interview not conducted for this assessment.

4.2 General Practitioner

GP records indicate opportunistic rather than systematic mental health management.

4.3 Family/Other

No additional corroborative sources accessed for this assessment.

5. Has the condition worsened or been aggravated as result of service with ADF after 25/05/2002?

Not applicable - member discharged 26/08/2000.

6. Details of event/incident after 25 Apr 1998 which aggravated diagnosed conditions

Not applicable - service concluded prior to this date.

7. Was the aggravation permanent or temporary?

Not applicable - condition caused by, not aggravated by, military service.

Clinical Examination

Current psychiatric status

Moderate to severe anxiety disorder with comorbid moderate depression and severe alcohol use disorder. Chronic course with incomplete treatment response.

1. Current cognitive status

Cognitive function grossly intact with subjective concentration difficulties attributable to anxiety and mood symptoms rather than primary cognitive disorder. No evidence of dementia or mild cognitive impairment.

2. Medical history

Multiple musculoskeletal conditions as documented, contributing to chronic pain syndrome which exacerbates psychiatric symptoms through bidirectional relationship between pain and mood.

3. Medical conditions directly impacting psychiatric condition

Chronic pain from multiple musculoskeletal injuries creates perpetuating factor for depression and anxiety. Hypercholesterolemia may indicate metabolic syndrome associated with psychiatric medications or lifestyle factors.

4. Social history

Married, employed, socially withdrawn. Wife provides primary support. Maintains employment despite symptoms. Severe social avoidance beyond family unit.

Supplementary Clinical Information

Clinical instruments administered:

• K10: Score 23 (High distress)
• DASS21: Depression 9 (Moderate), Anxiety 9 (Severe), Stress 10 (Moderate)
• GAD7: Score 11 (Moderate anxiety)
• PCL-5: Not administered as PTSD not primary diagnostic consideration

Diagnosis

1. Final diagnosis

Primary Diagnoses:

• Generalized Anxiety Disorder (F41.1)
• Major Depressive Disorder, Moderate, Single Episode (F32.1)
• Alcohol Use Disorder, Severe (F10.20)

Historical Diagnosis:

• Adjustment Disorder with Mixed Anxiety and Depressed Mood (at time of discharge)

2. DSM-5-TR diagnostic criteria

As detailed in diagnostic formulation section above, full criteria met for each diagnosis according to DSM-5-TR specifications.

3. Associated signs and symptoms

• Persistent worry and anxiety
• Psychomotor restlessness
• Irritability and impatience
• Social withdrawal
• Anhedonia
• Insomnia
• Fatigue
• Concentration difficulties
• Alcohol dependence
• Somatic symptoms including muscle tension

4. Does diagnosis include Substance Use Disorder?

Yes - Alcohol Use Disorder, Severe (F10.20)

5. History of consumption/use

5.1 Amount consumed

Currently 10 standard drinks nightly (approximately 100 grams pure alcohol)

5.2 Dates of increase/decrease

• Initial use during military service (1994-1996) as sleep aid
• Progressive escalation post-discharge
• Current pattern established over multiple years

5.3 Reason for increase/decrease

Self-medication for anxiety and insomnia. No successful decrease attempts documented.

6. Date of onset of conditions

• Adjustment Disorder: 1995 (during service)
• Evolution to Generalized Anxiety Disorder: 1996-2000
• Major Depressive Disorder: Crystallized by 2000
• Alcohol Use Disorder: Progressive from 1995, severe by 2000

7. Relationship between diagnosed conditions and events

7.1 Events before service

No significant contributory events. Normal developmental trajectory.

7.2 Events during service

CAUSED conditions - 100% attribution to service factors:

• Physical injury creating vulnerability
• Psychosocial stressors (parental separation)
• Institutional factors (denied compassionate leave)
• Moral injury from perceived abandonment
• Chronic pain from multiple injuries

7.3 Events after service

Maintaining factors only - original causation during service.

8. Specific stressor details

8.1 Dates

• August 1992 - December 1992: Initial training injuries
• 1995-1996: Parental separation and denied leave
• 1996-2000: Progressive symptom development

8.2 Location

• the RAAF base (injury)
• the RAAF base (ongoing stressors)

8.3 Nature of incidents

• Physical trauma during training
• Family crisis without support
• Institutional betrayal

8.4 Names of persons involved

Not specified in available documentation.

9. All events/stressors implicated in development

Most significant:

• Physical injury during training - initiated vulnerability
• Denied compassionate leave - moral injury
• Undiagnosed spinal fracture - invalidation
• Parental separation - loss of support
• Multiple somatic injuries - chronic pain

10. Contribution of service-related factors

Assessment of Impairment

Degree of impairment according to GARP 5th Edition: Total impairment rating of 30 points.

Apportionment:

• Generalized Anxiety Disorder: 60% (18 points)
• Major Depressive Disorder: 20% (6 points)
• Alcohol Use Disorder: 20% (6 points)

Prognosis

1. Would the claimant benefit from treatment?

Yes, substantial benefit expected from comprehensive treatment program addressing all diagnosed conditions concurrently.

2. What treatment would be beneficial?

Recommended treatment plan:

• Immediate: Establishment of GP Mental Health Care Plan with regular scheduled appointments
• Pharmacotherapy: SSRI/SNRI antidepressant (e.g., Duloxetine 60mg addressing both anxiety and pain)
• Psychological intervention: Cognitive Behavioral Therapy for anxiety and depression (minimum 12 sessions)
• Alcohol intervention: Supervised withdrawal if required, followed by relapse prevention program
• Pain management: Meloxicam for inflammatory component, physiotherapy for mechanical issues
• Sleep hygiene: Structured program with possible short-term hypnotic during alcohol cessation
• Duration: Minimum 12 months GP-led care with specialist psychiatry review at 3 months

3. Expected results from proposed treatment

With comprehensive treatment adherence:

• Expected improvement: 50% reduction in symptom severity possible though not guaranteed
• Functional improvement: Return to moderate social functioning achievable
• Alcohol cessation: Would significantly improve prognosis
• Timeline: Initial response within 6-8 weeks, maximal improvement at 12-18 months
• Barriers: Chronic pain may limit complete recovery

Permanency and Stability Assessment

Permanency: The conditions are considered permanent with residual impairment unlikely to fully resolve. Date of permanency: December 2020

Stability: The conditions have reached stability with current impairment level established. Date of stability: December 2020

Review recommendation: Reassessment in 12 months following treatment implementation to determine actual versus expected improvement.

Impairment rating tables (GARP Chapter 4)