Reference Determination Content
Suggested draft · fictitious patient
Chronic Insomnia Disorder
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 17 June 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 17 June 2025;
- A gynaecology consultation and hormone profile by the gynaecologist, dated 12 March 2009;
- A trauma admission and CT trauma series by Role 3 hospital, Afghanistan, dated 2 July 2010;
- A psychiatric assessment by the consultant psychiatrist, dated 5 December 2010;
- An audiology report by the audiologist, dated 5 December 2010;
- An emergency department record and CT head by the emergency physician, dated 20 April 2011;
- An intensive care discharge summary and MRI right tibia by the intensivist and orthopaedic surgeon, dated 14 June 2011;
- An infectious diseases consultation by the infectious diseases physician, dated 25 August 2011;
- A psychology progress note by the rehabilitation psychologist, dated 6 September 2011;
- A psychology review by the rehabilitation psychologist, dated 30 September 2011;
- An outpatient health record by the medical officer, Garrison health centre, dated 1 November 2011;
- A psychiatric review and sleep diary by the consultant psychiatrist, dated 23 January 2012;
- A medical employment classification notice by the defence, dated 15 February 2012;
- A psychiatric review by the consultant psychiatrist, dated 12 March 2012;
- A cognitive behavioural therapy for insomnia (initial session) by the clinical psychologist, dated 20 June 2012.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
15 February 1990 and 30 June 2014
Chronic Insomnia Disorder
You have stated that your condition was caused by:
- having a clinically significant disorder of mental health as specified within the one year before the clinical onset of chronic insomnia disorder
- experiencing a category 1A stressor within the one year before the clinical onset of chronic insomnia disorder
- experiencing a category 1B stressor within the one year before the clinical onset of chronic insomnia disorder
- experiencing a category 2 stressor within the one year before the clinical onset of chronic insomnia disorder
- experiencing severe childhood abuse before the clinical onset of chronic insomnia disorder
- 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
- having a severe, chronic medical condition within the one year before the clinical onset of chronic insomnia disorder
- having persistent pain for at least the three months before the clinical onset of chronic insomnia disorder
- having tinnitus for at least the three months before the clinical onset of chronic insomnia disorder
- being pregnant at the time of the clinical onset of chronic insomnia disorder
- 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
- 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
- being treated with mefloquine within the two months before the clinical onset of chronic insomnia disorder
Diagnosis: Chronic Insomnia Disorder
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 17 June 2025, and is supported by a psychiatric review and sleep diary by the consultant psychiatrist, dated 23 January 2012.
I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:
Statement of Principles concerning Chronic Insomnia Disorder (Balance of Probabilities) (No. 38 of 2019)
which sets out the factors that can connect the condition with service.
I am satisfied that you have met the following factor:
- having a clinically significant disorder of mental health as specified within the one year before the clinical onset of chronic insomnia disorder
- experiencing a category 1A stressor within the one year before the clinical onset of chronic insomnia disorder
- experiencing a category 1B stressor within the one year before the clinical onset of chronic insomnia disorder
- experiencing a category 2 stressor within the one year before the clinical onset of chronic insomnia disorder
- experiencing severe childhood abuse before the clinical onset of chronic insomnia disorder
- 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
- having a severe, chronic medical condition within the one year before the clinical onset of chronic insomnia disorder
- having persistent pain for at least the three months before the clinical onset of chronic insomnia disorder
- having tinnitus for at least the three months before the clinical onset of chronic insomnia disorder
- being pregnant at the time of the clinical onset of chronic insomnia disorder
- 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
- 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
- being treated with mefloquine within the two months before the clinical onset of chronic insomnia disorder
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with 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 on 1 November 2011.
The diagnosis was confirmed by a consultant psychiatrist on 23 January 2012 against the DSM-5 criteria set out in the Statement of Principles. You 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.
This has then led to further investigations and the diagnosis of your condition of Chronic Insomnia Disorder. I have accepted your condition of Chronic Insomnia Disorder.
Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that this condition is related to your peacetime service.
I have therefore accepted that this condition is related to your service with effect from 18 October 2011.
Chronic Insomnia Disorder (Worsening)
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 17 June 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 17 June 2025;
- A gynaecology consultation and hormone profile by the gynaecologist, dated 12 March 2009;
- A trauma admission and CT trauma series by Role 3 hospital, Afghanistan, dated 2 July 2010;
- A psychiatric assessment by the consultant psychiatrist, dated 5 December 2010;
- An audiology report by the audiologist, dated 5 December 2010;
- An emergency department record and CT head by the emergency physician, dated 20 April 2011;
- An intensive care discharge summary and MRI right tibia by the intensivist and orthopaedic surgeon, dated 14 June 2011;
- An infectious diseases consultation by the infectious diseases physician, dated 25 August 2011;
- A psychology progress note by the rehabilitation psychologist, dated 6 September 2011;
- A psychology review by the rehabilitation psychologist, dated 30 September 2011;
- An outpatient health record by the medical officer, Garrison health centre, dated 1 November 2011;
- A psychiatric review and sleep diary by the consultant psychiatrist, dated 23 January 2012;
- A medical employment classification notice by the defence, dated 15 February 2012;
- A psychiatric review by the consultant psychiatrist, dated 12 March 2012;
- A cognitive behavioural therapy for insomnia (initial session) by the clinical psychologist, dated 20 June 2012.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
15 February 1990 and 30 June 2014
Chronic Insomnia Disorder (Worsening)
You have stated that the worsening of your condition was caused by:
- having a clinically significant disorder of mental health as specified within the one year before the clinical worsening of chronic insomnia disorder
- experiencing a category 1A stressor within the one year before the clinical worsening of chronic insomnia disorder
- experiencing a category 1B stressor within the one year before the clinical worsening of chronic insomnia disorder
- experiencing a category 2 stressor within the one year before the clinical worsening of chronic insomnia disorder
- 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
- having a severe, chronic medical condition within the one year before the clinical worsening of chronic insomnia disorder
- having persistent pain for at least the three months before the clinical worsening of chronic insomnia disorder
- having tinnitus for at least the three months before the clinical worsening of chronic insomnia disorder
- being pregnant at the time of the clinical worsening of chronic insomnia disorder
- 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
- 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
- being treated with mefloquine within the two months before the clinical worsening of chronic insomnia disorder
- inability to obtain appropriate clinical management for chronic insomnia disorder
Diagnosis: Chronic Insomnia Disorder (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 17 June 2025, and is supported by a psychiatric review and sleep diary by the consultant psychiatrist, dated 23 January 2012.
I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:
Statement of Principles concerning Chronic Insomnia Disorder (Balance of Probabilities) (No. 38 of 2019)
which sets out the factors that can connect the condition with service.
I am satisfied that you have met the following factor:
- having a clinically significant disorder of mental health as specified within the one year before the clinical worsening of chronic insomnia disorder
- experiencing a category 1A stressor within the one year before the clinical worsening of chronic insomnia disorder
- experiencing a category 1B stressor within the one year before the clinical worsening of chronic insomnia disorder
- experiencing a category 2 stressor within the one year before the clinical worsening of chronic insomnia disorder
- 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
- having a severe, chronic medical condition within the one year before the clinical worsening of chronic insomnia disorder
- having persistent pain for at least the three months before the clinical worsening of chronic insomnia disorder
- having tinnitus for at least the three months before the clinical worsening of chronic insomnia disorder
- being pregnant at the time of the clinical worsening of chronic insomnia disorder
- 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
- 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
- being treated with mefloquine within the two months before the clinical worsening of chronic insomnia disorder
- inability to obtain appropriate clinical management for chronic insomnia disorder
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with 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 on 1 November 2011.
The diagnosis was confirmed by a consultant psychiatrist on 23 January 2012 against the DSM-5 criteria set out in the Statement of Principles. You 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.
After the condition arose, it was worsened during your service. 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. 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. The witnessed critical injury and resuscitation on 6 September 2011 fell within the year before the worsening on 12 March 2012. On 15 February 2012 you received written notice that your medical discharge was proceeding, adding to the ongoing work concerns and social isolation recorded through the year before the worsening. 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. Chronic tibial osteomyelitis requiring daily wound care and drug therapy continued through the year before the worsening. Continuous pelvic and leg pain requiring oxycodone persisted throughout the three months before the worsening, from 12 December 2011 to 12 March 2012. Constant bilateral tinnitus persisted throughout the three months before the worsening and was recorded as keeping your awake at night. You were 35 weeks pregnant on 12 March 2012 when the worsening was documented. 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. 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. 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. You were referred for cognitive behavioural therapy for insomnia on 1 November 2011, but no provider was available at the rehabilitation unit and your first session did not take place until 20 June 2012.
This has then led to further investigations and the diagnosis of your condition of Chronic Insomnia Disorder (Worsening). I have accepted your condition of Chronic Insomnia Disorder (Worsening).
Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that the worsening of this condition is related to your peacetime service.
I have therefore accepted that the worsening of this condition is related to your service with effect from 12 March 2012.
