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Statement of Principles

concerning

SCHIZOPHRENIA

No. 15 of 2009

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 schizophrenia No. 15 of 2009.

Determination

2. The Repatriation Medical Authority under subsection 196B(2) and (8) of the Veterans’ Entitlements Act 1986 (the VEA):

(a) revokes Instrument No. 132 of 1996 concerning schizophrenia; and

(b) determines in its place this Statement of Principles.

Kind of injury, disease or death

3. (a) This Statement of Principles is about schizophrenia and death from schizophrenia.

(b) For the purposes of this Statement of Principles, "schizophrenia" means a psychiatric disorder characterised by a range of cognitive and emotional dysfunctions associated with impaired occupational or social functioning, and which includes disturbances of perception, inferential thinking, language and communication, behavioural monitoring, affect, fluency and productivity of thought and speech, hedonic capacity, volition and drive, and attention. This condition meets the following diagnostic criteria (derived from DSM-IV-TR):

(A) The person has had two (or more) of the following characteristic symptoms, each present for a significant portion of time during a one month period (or less, if successfully treated):

(i) delusions;

(ii) hallucinations;

(iii) disorganised speech (e.g., frequent derailment or incoherence);

(iv) grossly disorganised or catatonic behaviour; or

(v) negative symptoms; (i.e., affective flattening, alogia, or avolition).

Only one criterion A symptom is required if delusions are bizarre; or hallucinations consist of a voice keeping up a running commentary on the person's behaviour or thoughts, or two or more voices conversing with each other.

(B) For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset.

(C) Continuous signs of the disturbance persist for at least six months. This six month period must include at least one month of symptoms (or less if successfully treated) that meet criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

(D) Schizoaffective disorder and mood disorder with psychotic features have been ruled out.

(E) The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

(F) If there is a history of autistic disorder or other pervasive developmental disorder, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).

(d) In the application of this Statement of Principles, the definition of "schizophrenia" is that given at paragraph 3(b) above.

Basis for determining the factors

4. The Repatriation Medical Authority is of the view that there is sound medical-scientific evidence that indicates that schizophrenia and death from schizophrenia 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.

Factors

6. The factor that must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting schizophrenia or death from schizophrenia with the circumstances of a person’s relevant service is:

(a) having experienced severe childhood abuse within the ten years before the clinical onset of schizophrenia; or

(b) experiencing the death of a related child within the five years before the clinical onset of schizophrenia; or

(d) having drug dependence or drug abuse, involving cannabis, within the ten years before the clinical onset of schizophrenia; or

(e) using cannabis at least twice a week for a continuous period of at least six months before the age of 18 years, within the ten years before the clinical onset of schizophrenia; or

(f) having viral meningitis, encephalitis or meningoencephalitis, before the age of sixteen years, where the clinical onset of schizophrenia occurs within the fifteen years following the infection with that viral meningitis, encephalitis or meningoencephalitis; or

(g) being infected with Toxoplasma gondii before the clinical onset of schizophrenia; or

(h) having a moderate to severe cerebral trauma at least one year, but not more than five years, before the clinical onset of schizophrenia; or

(i) undergoing a course of therapeutic radiation to the brain, where the first exposure occurred at least five years before the clinical onset of schizophrenia; or

(j) having received a cumulative equivalent dose of at least 0.3 Sievert of atomic radiation to the brain, where this dose was accumulated at least four years before the clinical onset of schizophrenia; or

(k) having experienced severe childhood abuse within the ten years before the clinical worsening of schizophrenia; or

(l) experiencing the death of a related child within the five years before the clinical worsening of schizophrenia; or

(m) experiencing a category 1A stressor within the six months before the clinical worsening of schizophrenia; or

(n) experiencing a category 1B stressor within the six months before the clinical worsening of schizophrenia; or

(o) having drug dependence or drug abuse at the time of the clinical worsening of schizophrenia; or

(p) having alcohol dependence or alcohol abuse at the time of the clinical worsening of schizophrenia; or

(q) being treated with a drug which is associated in the individual with the development of psychotic symptoms during drug therapy, and the cessation or significant reduction of the psychotic symptoms within days or weeks of discontinuing drug therapy, where treatment with the drug continued for at least the two days before the clinical worsening of schizophrenia; or

(r) taking a drug or a drug from the class of drugs in specified list 1 within the one month before the clinical worsening of schizophrenia; or

(s) having ceased or reduced antipsychotic drug therapy, within the seven days before the clinical worsening of schizophrenia; or

(t) having a clinically significant psychiatric condition at the time of the clinical worsening of schizophrenia; or

(u) inability to obtain appropriate clinical management for schizophrenia.

Factors that apply only to material contribution or aggravation

7. Paragraphs 6(k) to 6(u) apply only to material contribution to, or aggravation of, schizophrenia where the person’s schizophrenia 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 or more 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

"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;

(d) killing or maiming a person; or

(e) being an eyewitness to or participating in, the clearance of critically injured casualties;

"a clinically significant psychiatric condition" means any Axis 1 disorder of mental health that attracts a diagnosis under DSM-IV-TR which is sufficient to warrant ongoing management, which may involve regular visits (for example, at least monthly), to a psychiatrist, clinical psychologist or general practitioner;

"a course of therapeutic radiation" means one or more fractions (treatment portions) of ionising radiation administered with the aim of achieving palliation or cure with gamma rays, x-rays, alpha particles or beta particles;

"a drug or a drug from the class of drugs in specified list 1" means:

(a) amphetamines, including methamphetamine and 3,4-methylenedioxymethamphetamine (ecstasy);

(b) anabolic-androgenic steroids;

(d) cocaine;

(e) ephedrine;

(f) fenfluramine;

(g) hallucinogens;

(h) inhalants;

(i) interferons;

(j) opiates;

(k) phencyclidine;

(l) phentermine;

(m) phenylephrine;

(n) phenylpropanolamine; or

(o) pseudoephedrine;

"a related child" means your biological, adopted, step- or foster child;

"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;

"atomic radiation" means ionising radiation excluding:

(a) natural background radiation;

(b) therapeutic radiation; and

"being infected with Toxoplasma gondii" means serological evidence of infection with Toxoplasma gondii;

"cumulative equivalent dose" means the total equivalent dose of radiation from all types of ionising radiation. It accounts for the differences in biological effectiveness of various types of radiation and allows doses from different radiations to be combined. Each component is calculated by multiplying the absorbed dose in a particular tissue or organ for a given type of radiation by the radiation weighting factor for that radiation. The unit of equivalent dose is the Sievert;

"death from schizophrenia" in relation to a person includes death from a terminal event or condition that was contributed to by the person’s schizophrenia;

"DSM-IV-TR" means the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000;

"early-death of a parent" means the death of a parent before the child attains the age of 18 years;

"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), Sixth Edition, effective date of 1 July 2008, copyrighted by the National Centre for Classification in Health, Sydney, NSW, and having ISBN 978 1 74210 016 6;

"inhalants" means breathable chemicals that produce psychoactive vapours and include organic solvents, aerosols, some anaesthetics, and other chemicals;

"moderate to severe cerebral trauma" means structural injury or physiological disruption of brain function as a result of external force, accompanied by at least one of the following clinical signs immediately following the event:

(a) loss of consciousness lasting at least 30 minutes or posttraumatic anterograde amnesia lasting at least 24 hours;

(b) leakage of cerebrospinal fluid;

(d) seizures;

(e) intracranial abnormalities, including intracranial haemorrhage; intracranial haematoma; cerebral contusion; hydrocephaly and diffuse axonal injury; or

(f) a Glasgow Coma Scale score of 12 or less.

In this definition, external force includes blunt trauma; acceleration or deceleration forces; blast force or a foreign body penetrating the brain;

"relevant service" means:

(a) operational service under the VEA;

(b) peacekeeping service under the VEA;

(d) warlike service under the MRCA; or

(e) 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:

(a) pneumonia;

(b) respiratory failure;

(d) circulatory failure; or

(e) cessation of brain function.

Application

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 6 May 2009.

Dated this twenty-fourth day of April 2009

The Common Seal of the )

Repatriation Medical Authority )

was affixed to this instrument )

in the presence of: )

KEN DONALD

CHAIRPERSON