Statement of Principles
ACUTE STRESS DISORDER
No. 41 of 2014
for the purposes of the
Veterans’ Entitlements Act 1986
Military Rehabilitation and Compensation Act 2004
1. This Instrument may be cited as Statement of Principles concerning acute stress disorder No. 41 of 2014.
2. The Repatriation Medical Authority under subsection 196B(2) and (8) of the Veterans’ Entitlements Act 1986 (the VEA):
(a) revokes Instrument No. 33 of 2007 concerning acute stress disorder; and
(b) determines in its place this Statement of Principles.
Kind of injury, disease or death
3. (a) This Statement of Principles is about acute stress disorder and death from acute stress disorder.
(b) For the purposes of this Statement of Principles, "acute stress disorder" means a psychiatric disorder which meets the following criteria (derived from DSM-5):
A. The individual is exposed to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways:
(i) directly experiencing the traumatic event(s);
(ii) witnessing, in person, the event(s) as it occurred to others;
(iii) learning that the event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental; or
(iv) experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (for example, first responders collecting human remains, police officers repeatedly exposed to details of child abuse). This does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related; and
B. The presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred:
(i) recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed;
(ii) recurrent distressing dreams in which the content and/or affect of the dream are related to the event(s). In children, there may be frightening dreams without recognisable content;
(iii) dissociative reactions (for example, flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) In children, trauma-specific reenactment may occur in play;
(iv) intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolise or resemble an aspect of the traumatic event(s).
(i) persistent inability to experience positive emotions (for example, inability to experience happiness, satisfaction, or loving feelings).
(i) an altered sense of the reality of one’s surroundings or oneself (for example, seeing oneself from another’s perspective, being in a daze, time slowing);
(ii) inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
(i) efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s);
(ii) efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
(i) sleep disturbance (for example, difficulty falling or staying asleep, restless sleep);
(ii) irritable behaviour and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects;
(iv) problems with concentration;
(v) exaggerated startle response; and
C. Duration of the disturbance (symptoms in Criterion 2) is three days to one month after trauma exposure. Symptoms typically begin immediately after the trauma, but persistence for at least three days and up to one month is needed to meet disorder criteria; and
D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; and
E. The disturbance is not attributable to the physiological effects of a substance (for example, medication or alcohol) or another medical condition (for example, mild traumatic brain injury) and is not better explained by brief psychotic disorder.
Basis for determining the factors
4. The Repatriation Medical Authority is of the view that there is sound medical-scientific evidence that indicates that acute stress disorder and death from acute stress disorder can be related to relevant service rendered by veterans, members of Peacekeeping Forces, or members of the Forces under the VEA, or members under the Military Rehabilitation and Compensation Act 2004 (the MRCA).
Factors that must be related to service
5. Subject to clause 7, at least one of the factors set out in clause 6 must be related to the relevant service rendered by the person.
6. The factor that must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting acute stress disorder or death from acute stress disorder with the circumstances of a person’s relevant service is:
(a) experiencing a category 1A stressor within the one month before the clinical onset of acute stress disorder; or
(b) experiencing a category 1B stressor within the one month before the clinical onset of acute stress disorder; or
(c) experiencing the traumatic death of a significant other within the one month before the clinical onset of acute stress disorder; or
(d) having a significant other who experiences a category 1A stressor within the one month before the clinical onset of acute stress disorder; or
(e) being exposed to repeated or extreme aversive details of severe traumatic events within the one month before the clinical onset of acute stress disorder; or
(f) being the victim of severe childhood abuse within the one month before the clinical onset of acute stress disorder; or
(g) inability to obtain appropriate clinical management for acute stress disorder.
Factors that apply only to material contribution or aggravation
7. Paragraph 6(g) applies only to material contribution to, or aggravation of, acute stress disorder where the person’s acute stress disorder was suffered or contracted before or during (but not arising out of) the person’s relevant service.
Inclusion of Statements of Principles
8. In this Statement of Principles if a relevant factor applies and that factor includes an injury or disease in respect of which there is a Statement of Principles then the factors in that last mentioned Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.
9. For the purposes of this Statement of Principles:
"a category 1A stressor" means one of the following severe traumatic events:
(a) experiencing a life-threatening event;
(b) being subject to a serious physical attack or assault including rape and sexual molestation; or
(c) being threatened with a weapon, being held captive, being kidnapped, or being tortured;
"a category 1B stressor" means one of the following severe traumatic events:
(a) being an eyewitness to a person being killed or critically injured;
(b) viewing corpses or critically injured casualties as an eyewitness;
(c) being an eyewitness to atrocities inflicted on another person or persons;
(d) killing or maiming a person; or
(e) being an eyewitness to or participating in, the clearance of critically injured casualties;
"a significant other" means a person who has a close family bond or a close personal relationship and is important or influential in one’s life;
"an eyewitness" means a person who observes an incident first hand and can give direct evidence of it. This excludes a person exposed only to media coverage of the incident;
"being exposed to repeated or extreme aversive details of severe traumatic events" means witnessing a person suffering real, severe, traumatic events (for example, first responders collecting human remains, police officers repeatedly exposed to details of child abuse or drone operators viewing planned strikes) or repeatedly listening to a person's account of their exposure to severe traumatic events. This definition includes media exposure of the traumatic event (for example, electronic media, television images or photographs) where viewing these images is a work requirement;
"death from acute stress disorder" in relation to a person includes death from a terminal event or condition that was contributed to by the person’s acute stress disorder;
"DSM-5" means the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013;
"relevant service" means:
(a) operational service under the VEA;
(b) peacekeeping service under the VEA;
(c) hazardous service under the VEA;
(d) British nuclear test defence service under the VEA;
(e) warlike service under the MRCA; or
(f) non-warlike service under the MRCA;
"severe childhood abuse" means:
(a) serious physical, emotional, psychological or sexual harm whilst a child aged under 16 years; or
(b) neglect involving a serious failure to provide the necessities for health, physical and emotional development, or wellbeing whilst a child aged under 16 years;
where such serious harm or neglect has been perpetrated by a parent, a care provider, an adult who works with or around that child, or any other adult in contact with that child;
"terminal event" means the proximate or ultimate cause of death and includes:
(b) respiratory failure;
(c) cardiac arrest;
(d) circulatory failure; or
(e) cessation of brain function;
"traumatic death" means death which occurs in sudden, violent or traumatic circumstances such as homicide, suicide or an accidental death.
10. This Instrument applies to all matters to which section 120A of the VEA or section 338 of the MRCA applies.
Date of effect
11. This Instrument takes effect from 7 May 2014.
Dated this twenty-fourth day of April 2014
The Common Seal of the )
Repatriation Medical Authority )
was affixed to this instrument )
in the presence of: )
PROFESSOR NICHOLAS SAUNDERS AO