Emerging psychiatric inflation factors: Complex PTSD, gaming disorder and opioid dependence

In May 2019, the World Health Organisation (WHO) adopted the latest International Classification of Diseases (ICD-11). This included new psychiatric diagnoses which may increase the damages payable following bodily injury.

Complex PTSD (CPTSD)

To be diagnosed with PTSD, a claimant has to satisfy the following criteria:

  • Intrusive re-experiencing of the memories of the trauma
  • Avoidance of reminders
  • Persistent perception of heightened threat.

To be diagnosed with the new disorder of CPTSD, a claimant additionally has to suffer from:

  • Inappropriate emotional responses to minor events, such as overreacting and having difficulty calming down;
  • Persistent negative thoughts about themselves;
  • Difficulties sustaining relationships with others.

The first difference with CPSTD is therefore its potentially greater impact on personal relationships, including in the workplace where it can lead to prolonged sickness absence or even termination of employment due to behavioural issues.

The second difference is a longer and more expensive treatment phase. The British Psychological Society has indicated that up to 25 sessions of Cognitive Behavioural Therapy (CBT) could be needed.

Gaming disorder

Gaming Disorder is defined in ICD-11 as:

A pattern of gaming behaviour…characterised by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities…despite the occurrence of negative consequences.

The risk factors for a diagnosis of gaming disorder are immobilising injuries where the claimant is:

  • Socially isolated in their home
  • Likely to have more time to immerse themselves into the gaming world
  • Vulnerable due to a psychiatric element to their injuries.

It is known to develop in response to a life stress such as an accident. Statistically, the highest risk group is 13-25 year olds.

The sufferer will spend a vast number of hours playing video games, to the point of self-neglect, such that they may ignore their own personal hygiene, continue playing video games over eating, and have difficulties maintaining relationships with others. There is also the potential for consequent health problems, such as chronic back pain from long hours sitting in front of a screen.

Clinical evidence for effective treatment is still being gathered. Currently, gaming disorder can be treated on an out-patient basis, with the NHS offering a 12-week programme of individual and/or group counselling. Private clinics offer residential stays for treatment and costs can be in the region of £10,000 for a 4-week in-patient programme.

Opioid dependence

Opioid dependence is defined in ICD-11 as:

…a strong internal drive to use opioids, which is manifested by impaired ability to control use, increasing priority given to use over other activities and persistence of use despite harm or negative consequences…

There has been a 580% increase in prescribing high dose, long acting opioids in the last 20 years, driven by prescriptions for chronic pain and chronic post-surgical pain. A sufferer with a history of mental and substance misuse disorder is more likely to develop dependence to prescribed opioids.

Treatment typically includes a period of detoxification, talking therapy and after care. Private clinics offer a 4-week residential programme in the region of £25,000.

Claim implications

The diagnosis of an aggravating psychiatric disorder is very likely to increase a claimant’s basic award for pain, suffering and loss of amenity. The disorder’s adverse effects on lifestyle will then have knock-on effects in relation to financial losses flowing from the accident, including any combination of the following:

  • Loss of earnings, due to the inability to function at work.
  • Higher therapy claims, due to longer or more expensive rehabilitation pathways, including residential stays for serious cases.
  • Case management, where necessary to help coordinate rehabilitation.
  • Childcare fees, where a claimant was primary carer, especially if unavailable due to residential admission.
  • Tuition fees, where a claimant is no longer able to help children with their studies and/or their work suffers due to the disrupted home environment.
  • Travel claims, for therapies or if a claimant is no longer able to drive, including if disqualified following addiction to alcohol or drugs.
  • Money wasted due to the disorder, for example on cigarettes (but money wasted illegally will be irrecoverable for public policy, for example on drugs).

It will frequently be beneficial for compensators to invest in rehabilitation funding in order to promote the fastest recovery. Such disorders can be complex and high-level leadership will be required from clinical and/or medico-legal experts. Some innovative new treatments are emerging that offer more patient choice compared to traditional clinic-based counselling, such as:

  • Remote therapy via video calls or specialist apps, where a claimant is unable to travel to the clinic or lives in an area with inadequate local mental health services.
  • Virtual Reality Exposure Therapy, which offers a computer-generated virtual environment to help patients to therapeutically confront feared situations or locations in order to overcome PTSD.
  • An electrical stimulator (the ‘Bridge’ device) for the nerve field which reduces symptoms of opioid withdrawal.

Comment

Awareness of these new disorders is still growing amongst medical and claims professionals, but we expect to see an inflationary effect on both damages and claim reserves in the relevant cases, because of their disabling symptoms and prolonged treatment phase.
Clinical knowledge regarding the rehabilitation pathways will continue to improve and compensators should seek early guidance from suitably qualified and up-to-date experts and be prepared to fund therapies, especially if not otherwise available via the NHS, employer or health insurer.

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