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Statement of Principles

concerning

PANIC DISORDER

No. 68 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 panic disorder No. 68 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. 9 of 1999, as amended by Instrument No. 58 of 1999, concerning panic disorder; and

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

Kind of injury, disease or death

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

(b) For the purposes of this Statement of Principles, "panic disorder" means a psychiatric condition meeting the following diagnostic criteria (derived from DSM-IV-TR):

A. The person has experienced both:

(1) recurrent unexpected panic attacks; and

(2) at least one of the attacks has been followed by one month (or more) of one (or more) of the following:

(i) persistent concern about having additional attacks;

(ii) worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy"); or

(iii) a significant change in behaviour related to the attacks.

B. The panic attacks can occur in the presence or absence of agoraphobia.

C. The panic attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).

D. The panic attacks are not better accounted for by another mental disorder, such as social phobia (e.g., occurring on exposure to feared social situations), specific phobia (e.g., on exposure to a specific phobic situation), obsessive-compulsive disorder (e.g., on exposure to dirt in someone with an obsession about contamination), posttraumatic stress disorder (e.g., in response to stimuli associated with a severe stressor), or separation anxiety disorder (e.g., in response to being away from home or close relatives).

(d) In the application of this Statement of Principles, the definition of "panic disorder" 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 panic disorder and death from panic disorder 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 panic disorder or death from panic disorder with the circumstances of a person’s relevant service is:

(a) experiencing a category 1A stressor within the five years before the clinical onset of panic disorder; or

(b) experiencing a category 1B stressor within the five years before the clinical onset of panic disorder; or

(d) experiencing the death of a significant other within the two years before the clinical onset of panic disorder; or

(e) having a clinically significant psychiatric condition from specified list 1, at the time of the clinical onset of panic disorder; or

(f) having a medical illness or injury, which is life-threatening or which results in serious physical or cognitive disability, within the five years before the clinical onset of panic disorder; or

(g) having a moderate to severe cerebral trauma within the ten years before the clinical onset of panic disorder; or

(h) having epilepsy at the time of the clinical onset of panic disorder; or

(i) experiencing a category 1A stressor within the five years before the clinical worsening of panic disorder; or

(j) experiencing a category 1B stressor within the five years before the clinical worsening of panic disorder; or

(k) experiencing the death of a significant other within the two years before the clinical worsening of panic disorder; or

(l) having a clinically significant psychiatric condition from specified list 2, at the time of the clinical worsening of panic disorder; or

(m) having a medical illness or injury, which is life-threatening or which results in serious physical or cognitive disability, within the five years before the clinical worsening of panic disorder; or

(n) having epilepsy at the time of the clinical worsening of panic disorder; or

(o) inability to obtain appropriate clinical management for panic disorder.

Factors that apply only to material contribution or aggravation

7. Paragraphs 6(i) to 6(o) apply only to material contribution to, or aggravation of, panic disorder where the person’s panic 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 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 from specified list 1" means one of the Axis I or Axis II disorders of mental health listed below:

(a) a mood disorder;

(b) a substance dependence or substance abuse disorder;

(d) anxiety disorder;

(e) obsessive-compulsive disorder;

(f) phobic anxiety;

(g) posttraumatic stress disorder;

(h) substance-induced anxiety disorder;

(i) eating disorder;

(j) schizophrenia;

(k) avoidant personality disorder;

(l) borderline personality disorder;

(m) dependent personality disorder;

(n) histrionic personality disorder; or

(o) obsessive-compulsive personality disorder,

that attract a diagnosis under DSM-IV-TR and are severe enough to warrant ongoing management. The ongoing management may involve regular visits (for example, at least monthly), to a psychiatrist, clinical psychologist or general practitioner;

"a clinically significant psychiatric condition from specified list 2" means one of the Axis I disorders of mental health listed below:

(a) a mood disorder;

(b) a substance dependence or substance abuse disorder;

(d) anxiety disorder;

(e) obsessive-compulsive disorder;

(f) phobic anxiety;

(g) posttraumatic stress disorder;

(h) substance-induced anxiety disorder;

(i) eating disorder; or

(j) schizophrenia,

"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;

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

"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;

"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;

"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;

"obsessive-compulsive disorder" means a psychiatric condition that meets the following diagnostic criteria (derived from DSM-IV-TR):

A. Either obsessions or compulsions:

Obsessions as defined by (1), (2), (3), and (4):

(1) recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress;

(2) the thoughts, impulses, or images are not simply excessive worries about real-life problems;

(3) the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralise them with some other thought or action; and

(4) the person recognises that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion).

Compulsions as defined by (1) and (2):

(1) repetitive behaviours (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly; and

(2) the behaviours or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviours or mental acts either are not connected in a realistic way with what they are designed to neutralise or prevent or are clearly excessive.

B. At some point during the course of the disorder, the person has recognised that the obsessions or compulsions are excessive or unreasonable. This criteria does not apply to children.

C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person's normal routine, occupational (or academic) functioning, or usual social activities or relationships.

D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an eating disorder; hair pulling in the presence of trichotillomania; concern with appearance in the presence of body dysmorphic disorder; preoccupation with drugs in the presence of a substance use disorder; preoccupation with having a serious illness in the presence of hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a paraphilia; or guilty ruminations in the presence of major depressive disorder).

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;

"panic attack" means a discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:

(a) palpitations, pounding heart, or accelerated heart rate;

(b) sweating;

(d) sensations of shortness of breath or smothering;

(e) feeling of choking;

(f) chest pain or discomfort;

(g) nausea or abdominal distress;

(h) feeling dizzy, unsteady, light headed or faint;

(i) derealisation (feelings of unreality) or depersonalisation (being detached from oneself);

(j) fear of losing control or going crazy;

(k) fear of dying;

(l) paraesthesias (numbness or tingling sensations); or

(m) chills or hot flushes.

This definition is derived from DSM-IV-TR;

"phobic anxiety" means a psychiatric condition which significantly limits an individual’s normal routine, occupational and social activities by excessive or unreasonable persistent fears brought on by the presence or anticipation of certain situations or objects. The exposure to the stimulus invariably provokes an immediate anxiety response such as a panic attack and the response is recognised as being excessive or unreasonable by the affected individual. This definition includes the diagnoses agoraphobia, social phobia or a specific phobia as derived from DSM-IV-TR;

"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;

"substance-induced anxiety disorder" means a psychiatric condition that meets the following diagnostic criteria (derived from DSM-IV-TR):

A. Prominent anxiety, panic attacks, or obsessions or compulsions predominate in the clinical picture.

B. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2):

(1) the symptoms in Criterion A developed during, or within 1 month of, substance intoxication or withdrawal;

(2) medication use is aetiologically related to the disturbance.

C. The disturbance is not better accounted for by an anxiety disorder that is not substance induced. Evidence that the symptoms are better accounted for by an anxiety disorder that is not substance induced might include the following: the symptoms precede the onset of the substance use (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or there is other evidence suggesting the existence of an independent non-substance-induced anxiety disorder (e.g., a history of recurrent non-substance-related episodes).

D. The disturbance does not occur exclusively during the course of a delirium.

E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

This diagnosis should be made instead of a diagnosis of substance intoxication or substance withdrawal only when the anxiety symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the anxiety symptoms are sufficiently severe to warrant independent clinical attention;

"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 11 November 2009.

Dated this twenty-eighth day of October 2009

The Common Seal of the )

Repatriation Medical Authority )

was affixed to this instrument )

in the presence of: )

KEN DONALD

CHAIRPERSON