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Case study 3 – psychiatric injury

Our ref: MICS 003/18

Introduction

The claimant was driving in moderately paced traffic and was rear ended by another vehicle, with the claimant’s car being shunted into the vehicle in front. The claimant did not lose consciousness. The claimant’s vehicle was drivable but subsequently reported to be “written off”. The claimant noted no awareness of physical or psychological symptoms at the time of the motor vehicle accident (MVA) and drove home “slowly”.

The claimant saw a treating physician the following day and was noted to have neck and shoulder symptoms, and fearfulness of driving. The claimant attended a Psychologist once as part of treatment, but was not provided with any exercises or benefit and so ceased treatment.

The claimant noted having “family problems” commencing late 2017 and continuing into early 2018.

The claimant has a number of educational qualifications and is currently completing a University level qualification. Time has been taken off for reasons a physical illness not related to the MVA which resulted in a hospital admission. As such, the claimant had fallen behind in the educational course work by three weeks.

The claimant uses two (2) Panadol a day, and previously (following the MVA, for approximately one month) had used Endep (antidepressant) to assist in sleep and Celebrex (anti-inflammatory) to assist in pain management.

The psychological assessment

Pre-MVA

  • Studying 5 days per week, plus four (4) hours study after formal classes
  • Working part time in hospitality (customer facing role)
  • Family and friends social engagement
  • Completion of household chores
  • Sleep noted to be undisturbed and
  • Driving independently

During assessment

  • Does not drive despite having been bought a car by the family, uses Ubers, taxis, and friends to transport and has plans to start driving in the future but has not commenced
  • Despite preferring not to think about the accident, noted no change in affect when recounting the MVA
  • Spent time away from friends/social groups however has commenced re-engagement with friends
  • Reported hospitalisation at the end of the first quarter of 2018, unrelated to MVA, however was discharged after 3-4 days on antibiotics. This resulted in non-attendance at university study for 3 weeks, but has caught up in university study since that time
  • Sleep disturbed, waking once or twice during the night, however clinically does not meet the criteria for middle insomnia
  • Self-reported “depression” clinically noted to last between minutes to hours and is able to distract themselves from depressive symptoms easily and
  • Has not returned to work in the hospitality setting, reportedly due to physical components of the MVA in addition to the higher demands of university study during the year.

There was no reported panic, re-experiencing, or nocturnal nightmares, and the claimant does not have clinically noted sleep difficulty. The claimant’s presentation was positive inclusive of “good self-care, polite and well dressed”. The claimant has driven past the accident site without any reported difficulty and did not change affect when discussing the injury.

Review of documentation

General Practitioner (GP) notes indicate physical injuries and presentation. Confirmation of physiotherapy sessions and confirmation of treatment including acupuncture and massage. GP notes indicate one (1) psychological session.

The Psychologist’s notes indicate a DASS score indicative of “severe” levels of anxiety and depression. Based on the self-report from the claimant during assessment, symptoms have significantly reduced. The claimant identified that symptoms at the time of the DASS score were exacerbated by family issues, withdrawing from friends, and prior to commencement of university study (cognitive engagement). These factors are noted to corroborate with the claimant’s self-assessment.

Diagnosis

Adjustment Disorder with Anxiety. Anxiety is present and disproportionate to the intensity of the stressor (MVA with physical injuries).

The claimant does not have the cardinal feature required for a Major Depressive Disorder diagnosis or the duration or severity of symptoms required for a dysthymia (persistent mild depression).

The claimant does not have symptoms for Generalised Anxiety Disorder nor panics required for this diagnosis.

The claimant has clinical severity of cluster C symptoms (persistent avoidance) for Posttraumatic Stress Disorder (PTSD), but no other domains. As such they do not meet the diagnostic criteria for PTSD.

Minor Injury

Section 1.6(3) of the Act:

A minor psychological or psychiatric injury is a psychological or psychiatric injury that is not a recognised psychiatric illness.

Part 1 clause 4 (2) of the Motor Vehicle Injuries Regulation 2017:

2) Each of the following injuries is included as a minor psychological or psychiatric injury

a) acute stress disorder

b) adjustment disorder

3) in the clause, acute stress disorder and adjustment disorder have the same meanings as in the document entitled Diagnostic and Statistical manual of Mental Disorders (DSM-5)

As in the diagnosis and reasons above, the claimant only meets the criteria for an Adjustment Disorder and not for any specific psychiatric disorder. The Adjustment Disorder with anxiety DSM F43.22 is a minor injury.