Statement of Principles
concerning
ANXIETY DISORDER
No. 103 of 2014
for the purposes of the
Veterans’ Entitlements Act 1986
and
Military Rehabilitation and Compensation Act 2004
Title
1. This Instrument may be cited as Statement of Principles concerning anxiety disorder No. 103 of 2014.
Determination
2. The Repatriation Medical Authority under subsection 196B(3) and (8) of the Veterans’ Entitlements Act 1986 (the VEA):
(a) revokes Instrument No. 102 of 2007 concerning anxiety 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 anxiety disorder and death from anxiety disorder.
(b) For the purposes of this Statement of Principles, "anxiety disorder" means generalised anxiety disorder, anxiety disorder due to another medical condition, other specified anxiety disorder or unspecified anxiety disorder, where:
"generalised anxiety disorder" means a mental disorder that meets the following diagnostic criteria (derived from DSM-5):
A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least six months, about a number of events or activities (such as work or school performance);
B. The individual finds it difficult to control the worry;
C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past six months):
Note: Only one item is required in children.
(i) restlessness or feeling keyed up or on edge;
(ii) being easily fatigued;
(iii) difficulty concentrating or mind going blank;
(iv) irritability;
(v) muscle tension; or
(vi) sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep);
D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning;
E. The disturbance is not attributable to the physiological effects of a substance (for example, a drug of abuse, a medication) or another medical condition (for example, hyperthyroidism); and
F. The disturbance is not better explained by another mental disorder (for example, anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).
"anxiety disorder due to another medical condition" means a mental disorder that meets the following diagnostic criteria (derived from DSM-5):
A. Panic attacks or anxiety is predominant in the clinical picture;
B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition;
C. The disturbance is not better explained by another mental disorder;
D. The disturbance does not occur exclusively during the course of a delirium; and
E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
"other specified anxiety disorder" and "unspecified anxiety disorder" are mental disorders (derived from DSM-5) with prominent symptoms of anxiety that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, however, these anxiety symptoms do not meet the full diagnostic criteria for any of the other anxiety disorders.
This definition of anxiety disorder excludes the other anxiety disorders: agoraphobia, panic disorder, selective mutism, separation anxiety disorder, social anxiety disorder, specific phobia and substance-induced anxiety disorder.
(c) Anxiety disorder attracts ICD-10-AM code F06.4, F41.1, F41.8 or F41.9.
(d) In the application of this Statement of Principles, the definition of "anxiety disorder" is that given at paragraph 3(b) above.
Basis for determining the factors
4. On the sound medical-scientific evidence available, the Repatriation Medical Authority is of the view that it is more probable than not that anxiety disorder and death from anxiety disorder can be related to relevant service rendered by veterans 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.
Factors
6. The factor that must exist before it can be said that, on the balance of probabilities, anxiety disorder or death from anxiety disorder is connected with the circumstances of a person’s relevant service is:
(a) for generalised anxiety disorder, other specified anxiety disorder or unspecified anxiety disorder only:
(i) experiencing a category 1A stressor within the two years before the clinical onset of anxiety disorder; or
(ii) experiencing a category 1B stressor within the two years before the clinical onset of anxiety disorder; or
(iii) having a significant other who experiences a category 1A stressor within the one year before the clinical onset of anxiety disorder; or
(iv) experiencing a category 2 stressor within the six months before the clinical onset of anxiety disorder; or
(v) having a clinically significant disorder of mental health as specified within the five years before the clinical onset of anxiety disorder; or
(vi) having a medical illness or injury which is life-threatening or which results in serious physical or cognitive disability, within the two years before the clinical onset of anxiety disorder; or
(vii) having epilepsy at the time of the clinical onset of anxiety disorder; or
(viii) having persistent pain of at least six months duration at the time of the clinical onset of anxiety disorder; or
(ix) experiencing the death of a significant other within the one year before the clinical onset of anxiety disorder; or
(x) being the victim of severe childhood abuse before the clinical onset of anxiety disorder; or
(xi) being obese at the time of the clinical onset of anxiety disorder; or
(b) for anxiety disorder due to another medical condition only, having an endocrine, cardiovascular, respiratory, metabolic, infectious, or neurological disorder, where the medical condition is a direct physiological cause of the anxiety at the time of the clinical onset of anxiety disorder; or
(c) experiencing a category 1A stressor within the two years before the clinical worsening of anxiety disorder; or
(d) experiencing a category 1B stressor within the two years before the clinical worsening of anxiety disorder; or
(e) having a significant other who experiences a category 1A stressor within the one year before the clinical worsening of anxiety disorder; or
(f) experiencing a category 2 stressor within the six months before the clinical worsening of anxiety disorder; or
(g) having a clinically significant disorder of mental health as specified within the five years before the clinical worsening of anxiety disorder; or
(h) having a medical illness or injury which is life-threatening or which results in serious physical or cognitive disability, within the two years before the clinical worsening of anxiety disorder; or
(i) having epilepsy at the time of the clinical worsening of anxiety disorder; or
(j) having persistent pain of at least six months duration at the time of the clinical worsening of anxiety disorder; or
(k) experiencing the death of a significant other within the one year before the clinical worsening of anxiety disorder; or
(l) being the victim of severe childhood abuse before the clinical worsening of anxiety disorder; or
(m) being obese at the time of the clinical worsening of anxiety disorder; or
(n) having a medical condition as specified at the time of the clinical worsening of anxiety disorder; or
(o) inability to obtain appropriate clinical management for anxiety disorder.
Factors that apply only to material contribution or aggravation
7. Paragraphs 6(c) to 6(o) apply only to material contribution to, or aggravation of, anxiety disorder where the person’s anxiety 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.
Other definitions
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 category 2 stressor" means one of the following negative life events, the effects of which are chronic in nature and cause the person to feel on-going distress, concern or worry:
(a) being socially isolated and unable to maintain friendships or family relationships, due to physical location, language barriers, disability, or medical or psychiatric illness;
(b) experiencing a problem with a long-term relationship including the break-up of a close personal relationship, the need for marital or relationship counselling, marital separation, or divorce;
(c) having concerns in the work or school environment including on-going disharmony with fellow work or school colleagues, perceived lack of social support within the work or school environment, perceived lack of control over tasks performed and stressful work loads, or experiencing bullying in the workplace or school environment;
(d) experiencing serious legal issues including being detained or held in custody, on-going involvement with the police concerning violations of the law, or court appearances associated with personal legal problems;
(e) having severe financial hardship including loss of employment, long periods of unemployment, foreclosure on a property, or bankruptcy;
(f) having a family member or significant other experience a major deterioration in their health; or
(g) being a full-time caregiver to a family member or significant other with a severe physical, mental or developmental disability;
"a clinically significant disorder of mental health as specified" means one of the following conditions, which is of sufficient severity to warrant ongoing management, which may involve regular visits (for example, at least monthly) to a psychiatrist, counsellor or general practitioner:
(a) a bipolar disorder or related disorder;
(b) a depressive disorder;
(c) a disruptive, impulse-control or conduct disorder;
(d) a dissociative disorder;
(e) a feeding disorder or eating disorder;
(f) a neurocognitive disorder;
(g) a neurodevelopmental disorder;
(h) a paraphilic disorder;
(i) a personality disorder;
(j) a schizophrenia spectrum disorder or other psychotic disorder;
(k) a sexual dysfunction;
(l) a sleep-wake disorder;
(m) a somatic symptom disorder or related disorder;
(n) a trauma and stressor-related disorder;
(o) an obsessive compulsive disorder or related disorder;
(p) another anxiety disorder; or
(q) gender dysphoria;
"a medical condition as specified" means an endocrine, cardiovascular, respiratory, metabolic, infectious, or neurological condition, that causes symptoms consistent with anxiety and panic attacks as a direct physiological consequence of the condition;
"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 obese" means an increase in body weight by way of fat accumulation which results in a Body Mass Index (BMI) of 30 or greater.
The BMI = W/H2 and where:
W is the person's weight in kilograms; and
H is the person's height in metres;
"death from anxiety disorder" in relation to a person includes death from a terminal event or condition that was contributed to by the person’s anxiety disorder;
"DSM-5" means the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013;
"ICD-10-AM code" means a number assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM), Eighth Edition, effective date of 1 July 2013, copyrighted by the Independent Hospital Pricing Authority, and having ISBN 978-1-74128-213-9;
"persistent pain" means:
(a) continuous;
(b) almost continuous; or
(c) frequent, severe, intermittent pain,
which may or may not be ameliorated by analgesic medication and is of a level to cause interference with usual work or leisure activities or activities of daily living;
"relevant service" means:
(a) eligible war service (other than operational service) under the VEA;
(b) defence service (other than hazardous service and British nuclear test defence service) under the VEA; or
(c) peacetime 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:
(a) pneumonia;
(b) respiratory failure;
(c) cardiac arrest;
(d) circulatory failure; or
(e) cessation of brain function;
"the medical condition is a direct physiological cause of the anxiety" means one or more of the medical condition's signs or symptoms present as signs or symptoms of anxiety or panic attacks and are directly related to the pathological process of the medical condition, and:
(a) the anxiety disorder has a close temporal relationship with the onset or exacerbation of the medical condition, and the anxiety disorder developed at the same time or after the onset of the medical condition;
(b) treatment which causes remission of the medical condition also results in remission of the anxiety symptoms; or
(c) features of the anxiety disorder, such as an unusual age of onset, a qualitative difference in symptoms, or disproportionately severe or unusual symptoms, are inconsistent with a primary diagnosis of any of the anxiety spectrum disorders.
Application
10. This Instrument applies to all matters to which section 120B of the VEA or section 339 of the MRCA applies.
Date of effect
11. This Instrument takes effect from 17 November 2014.
Dated this seventeenth day of October 2014
The Common Seal of the )
Repatriation Medical Authority )
was affixed at the direction of: )
PROFESSOR NICHOLAS SAUNDERS AO
CHAIRPERSON
