Being involved in a motor vehicle accident (MVA) is undoubtedly stressful. In serious MVAs, it can cause both physical and psychological injuries. However, for minor MVAs, the psychological stress is unlikely to exceed the normal vicissitudes of life. Yet, under the Compulsory Third Party (CTP) insurance scheme, PTSD is not infrequently listed as an injury for a claim for a minor MVA.
CTP is a type of insurance that protects drivers and vehicle owners from financial liability if they cause injury or death in an MVA. CTP insurance is mandatory in all Australian states and territories and is a condition of vehicle registration. A claim for psychological injury requires a recognised psychiatric diagnosis, such as PTSD.
This article explores the background of PTSD and the diagnostic requirements under the CTP programme. It questions if the condition is overdiagnosed and whether this complies with the requirement under the Motor Accident Injuries Act 2017 (NSW) (MAIA).
policy guidelines
Under MAIA s 1.6(1)(b), a claim for psychological or psychiatric injury requires that the condition be a recognised psychiatric illness. The reasons for this are stated in the Object under MAIA s 1.3(2)(d): to keep premiums for policies affordable.
MAIA s 10.2 allows for the issue of the Motor Accident Guidelines (MAGS) which provide details on the diagnosis of psychiatric and other injuries. The MAGS are not meant to reflect contemporary medicine per se, but rather, they give prescriptive instructions specific to CTP claims.
For example, the latest MAGS is version 9.2, which is effective from 10 November 2023 onwards. For the assessment of physical injuries, the MAGS relies on the American Medical Association's Guides to the Evaluation of Permanent Impairment (AMA Guides). It currently uses the 4th Edition (3rd printing, 1995) even though the current version of the AMA Guides is the 6th edition, which was effective from 1 December 2024.
Although the Personal Injury Commission (PIC) is the independent statutory tribunal resolving disputes in both motor accidents and workplaces, it currently uses two different versions of the AMA Guides for physical injuries, neither of which are clinically current. The AMA Guides 5th edition, published in 2000, is used in the NSW Workers Compensation Guidelines (WCG) for the evaluation of permanent impairment (4th edition, reissued 1 March 2021). As mentioned above, the MAGS uses the 4th edition.
For psychological injuries, the MAGS uses the Diagnostic and Statistical Manual of Mental Disorders (DSM). The present version of MAGS relies on the current DSM 5th Edition, Text Revision (DSM-5-TR). In contrast, the present WCG uses “a psychiatric diagnosis (according to a recognised diagnostic system) and the report must specify the diagnostic criteria upon which the diagnosis is based” but cites the DSM 4th edition, text revision (DSM-4-TR).[1]
DSM PTSD Diagnosis – A Brief History
Exposure to potentially traumatic events (PTEs) is an essential component of the diagnostic criteria for PTSD under the DSM diagnostic system. PTSD was first included as a recognised psychiatric illness in the 3rd edition (DSM-3). Under the DSM system, various criteria must be met for each diagnosis. For PTSD under the current edition of DMS-5-TR, there are criteria A to H.
Criterion A plays a key gatekeeping role for PTSD because it determines which stressor events qualify as PTEs and, therefore, can be assessed for PTSD.[2] How criterion A is defined directly impacts a CTP claim because it establishes eligibility to receive a PTSD diagnosis and whether psychological harm in the form of PTSD was either caused or aggravated by an MVA.[3]
In DSM-3, criterion A PTEs was defined as the “existence of a recognisable stressor that would evoke significant symptoms of distress in almost everyone”.[4] This meant it only included PTEs that were outside the range of normal experiences (i.e. beyond the normal vicissitudes of life).
In the later DSM-3-TR edition,[5] criterion A was further narrowed to only those PTEs that were “a serious threat to one’s life or physical integrity; serious threat or harm to one’s children, spouse, or other close relatives and friends… or seeing another person who has recently been, or is being seriously injured or killed as the result of an accident…”[6]
In DSM-4, criterion A was split into two parts. Criterion A1 is an objective evaluation, stating that the individual “experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or the threat to physical integrity of self or others”. Criterion A2 then allows for the subjective evaluation of the event by the individual’s response.
In DSM-5, the definition of criterion A PTEs eliminated the DSM-4 subjective evaluation criterion A2. It expanded the explanation of the DSM-4 objective evaluation criterion A1. The current DSM-5-TR for PTSD criterion A for adults made no new changes to that found in DSM-5.
The evolution of the DSM criteria for PTSD has been based on research and clinical observations as they become available. As it evolved, it provided greater specificity in the details that comprise criterion A, especially in the accompanying descriptive text. The descriptive text for DSM-5 and the current DSM-5-TR states that MVAs under criterion A involve severe motor vehicle accidents.
dSM And cTP
The evolution of the DSM criteria for PTSD shows that, in the context of CTP claims for MVAs, PTSD diagnoses were only intended for severe MVAs. This is also the basis that actuaries used to calculate and price affordable premiums.
What constitutes “severe” is not defined by the DSM, but would likely include MVAs that threatened life, caused severe physical harm, exposed the person to grotesque, violent or sudden loss, or resulted in death or injury to others. Minor MVAs would not meet this threshold.
The NSW Police Force defines “minor MVA” as an incident where all involved parties exchange particulars, no drivers appear under the influence of drugs or alcohol, no vehicles require towing due to the crash, and no person is injured or seeks medical treatment within 24 hours of the crash.[7] This definition is a useful reference when assessing a CTP claim as to whether criterion A of PTSD is met under DSM-5 and DSM-5-TR.
overdiagnosis
Despite the prescriptive and objective nature of the DSM-5 and DSM-5-TR criterion A, anecdotal evidence suggests that PTSD is overdiagnosed in CTP claims. However, this is not always attributable to treating doctors. Australian clinicians do not universally adopt the DSM criteria, and A often rely on subjective clinical measures based on professional training, or alternative diagnostic systems, such as the World Health Organisation diagnostic criteria in ICD-11 (6B40) (ICD-11) instead.
The ICD-11 use a broader definition of criterion A, requiring “exposure to an event or situation…of an extremely threatening or horrific nature…which includes, but are not limited to,… serious accidents”.[8]
When broader criteria for PTSD are used by clinicians, this does not mean that the diagnostic label should automatically be applied to CTP claims. Furthermore, PIC medical assessors (MA) must be vigilant in distinguishing between an assessment based on contemporary clinical practice versus the requirement of applying the specific DSM criteria cited in the MAGS in the context of CTP claims. MAs need to distinguish between clinical judgement and the legal requirements under MAIA. At a minimum, MAs should ensure criterion A is strictly met to avoid overdiagnosis of PTSD.
Overdiagnosis of PTSD may also arise from reliance on “screening tools” such as the “PTSD Checklist for DSM-5” (PCL-5).[9] The PCL-5 is a 20-item self-report measure used to:[10]
- Monitor symptom changes during and after treatment;
- Screen individuals for PTSD; and
- Provide a provisional PTSD diagnosis
The PCL-5 does not assess trauma-relatedness of symptoms or functional impairment.[11] In other words, the findings do not necessarily infer a traumatic cause. Any result does not point to an MVA as the cause and when used solely, fails the legal causation requirement under MAIA.
There is also an issue of the PCL-5 in relation to any threshold for provisional diagnosis. Optimal PCL-5 cut-off scores vary widely across studies, populations, and types of traumatic events.[12] The choice of a cut-off score is dependent on the goals of the assessment and the population being assessed. The lower the cut-off score, the more lenient the criteria for inclusion, increasing the possible number of false positives.
The PCL-5 as a self-reported measure is dependent on the responses to the PCL-5 items answered through an individual’s subjective understanding, awareness of their symptoms, and their motivation to respond attentively and honestly. In the context of insurance claims, such biases are particularly relevant. These limitations may also conflict with the DSM’s move away from subjective evaluations (as was found in DSM-4 criterion A2) to a more objective focus (as adopted in DSM-5 and DSM-5-TR).
conclusion
To ensure the sustainability of the CTP programme, and maintain affordable premiums, strict adherence to the DSM-5-TR diagnostic criteria for PTSD, particularly criterion A, is essential. The adherence also provides consistency and predictability in assessments, enabling the PIC to uphold its Charter to deliver fair and just outcomes.[13]
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[1] SIRA (1 March 2021) NSW workers compensation guidelines for the evaluation of permanent impairment https://www.sira.nsw.gov.au/resources-library/workers-compensation-resources/publications/health-professionals-for-workers-compensation/workers-compensation-guidelines-for-the-evaluation-of-permanent-impairment?result_64356_result_page=11&id=329613
[2] Weathers FW, Keane TM. (2007) The Criterion A problem revisited: controversies and challenges in defining and measuring psychological trauma. J Trauma Stress. Apr;20(2):107-21.
[3] Kilpatrick, D. G., McFarlane, A. C., & Guarnera, L. A. (2021). PTSD and the law: Forensic considerations. In M. J. Friedman, P. P. Schnurr, & T. M. Keane (Eds.), Handbook of PTSD: Science and practice (3rd ed., pp. 501–517). The Guilford Press.
[4] American Psychiatric Association (APA), 1980, p. 238
[5] A “Text Revision” TR-edition is a minor update to the numbered edition that the APA does not deem sufficient to make it a new numbered edition.
[6] Edited for CTP relevance.
[7] NSW Police Force (nd) Minor Traffic Crash https://portal.police.nsw.gov.au/s/minor-traffic-crash-definition
[8] WHO (2024) ICD-11 for Mortality and Morbidity Statistics – PTSD https://icd.who.int/browse/2024-01/mms/en#2070699808
[9] Weathers F, Litz B, Herman D, Huska J, Keane T. (1993) The PTSD checklist: reliability, validity, & diagnostic utility. Annual Meeting of the International Society of Traumatic Stress Studies, San Antonio, TX.
[10] National Center for PTSD (20 November 2024) PTSD Checklist for DSM-5 (PCL-5) https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp
[11] Lindsay B. Kramer, Sarah E. Whiteman, Jessica M. Petri, Elizabeth G. Spitzer, and Frank W. Weathers (2023)Self-Rated Versus Clinician-Rated Assessment of Posttraumatic Stress Disorder: An Evaluation of Discrepancies Between the PTSD Checklist for DSM-5 and the Clinician-Administered PTSD Scale for DSM-5. Assessment 30(5), 1590-1605.
[12] Ibid.
[13] PIC (27 March 2024) Access Charter https://www.pi.nsw.gov.au/resources/policy/access-charter
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